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Volume II 


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141-145 West 36th Stbeet 

^{l Righti reterved 


New Yobk 


Plate 57. 

Fig. 89. Lingua scrotalis. 

hig. 90. .Aphtiiae. 

Lingua Scrotalis 

Plate 57, Fig. 89 

This affection, scrotal tongne, so-called from its resemblance to a 
contracted scrotum, is also known as lingua plicata, and by Mikulicz 
is called macroglossia with furrow formation. This affection is 
purely congenital and has also a familial incidence. The entire 
tongue is symmetrically enlarged, but is of normal contour. Its sur- 
face, however, instead of being smooth, is thrown into folds, numer- 
ous, and showing considerable bilateral symmetry. The median fold, 
corresponding to the middle line, is the deepest, as a rule. The entire 
tongue seems to be marked off into lobules. The papillae are not 
enlarged and may be missing. 

There are no especial symptoms beyond what has already been 
stated. The condition roughly resembles the lobulation which fol- 
lows sclerotic glossitis. The geographic tongue sometimes shows 


There are no indications whatever for treatment, at least none 
which could be carried out. 

Pig. 89. Model in Freiburg Clinic (Johnsen). 


Plate 57, Fig. 90 

Aphthfe or aphthous stomatitis is an affection described in 1823 by 
Billard, characterized by multiple white circumscribed, superficial 
fibrinous patches. Fibrin is deposited in the midst of the epithelial 
cells with resulting death of the same. 

The clinical picture is highly characteristic. In any locality in the 
mouth, notably on the tongue and lips, there appears an eruption of 
white or yellowish spots, these vary in size and are round or oval, and 
sharp contoured. They run a brief course and the epithelium is then 
exfoliated or shed, revealing a newly regenerated layer. The disease 
is kept up by the continuous formation of new aphthae. The lesions 
are extremely sensitive, so that eating and speech are difficult. As 
the affection is largely peculiar to young infants — one to three years 
of age — it is prone to be attended by fever. Salivation is naturally 
present. "Women also suffer from it in connection with all of the 
reproductive phenomena, and a stomatitis aphthosa not distinguish- 
able in any way often complicates the acute infectious diseases of 
childhood. Certain individuals seem to be predisposed to attacks of 


Aphthae of the mucosa appear to resemble closely vesicles OH the 
skin, save that the exudate in the former is fibrinous. Impetigo has 
been produced artificially from inoculation with aphthous material. 
The staphylococcus aureus is often met with in the secretion of 
aphthae. Children who are subject to aphthae either have diminished 
general resistance, as in scrofula and rickets, or the mouth is in a 
vulnerable condition from some pre-existing local disease. 


The possibility of foot-and-mouth disease must be kept in mind. 


Prognosis and Treatment 

Aphthae are so sure of spontaneous cure after a varying interval 
that their clinical importance is inferior. The tendency to recurrence 
of the lesions furnishes the real indication of treatment, but nothing 
is required beyond the use of antiseptic mouth washes. Caustics do 
not do good. General roborant measures are naturally indicated. 

Fig. 90. Model in Polyclinic of Prof. M. Joseph in Berlin (Kolhow). i 

109 ' 

Stomatitis Mercurialis 

Plate 58, Fig. 91 

This affection, due to general mercurial intoxication, bears so close 
a resemblance to ordinary ulcerous stomatitis as at first sight to 
suggest that there is no specificity involved. It begins about the teeth, 
especially carious teeth and stumps and the -wisdom teeth. The in- 
volved gums swell, and salivation is present. Next the portions of 
the cheeks and tongue which come in contact with the affected teeth 
participate. At the same time the process extends along the gums. 
At the junction of the latter with the teeth a yellow, pultaeeous mass 
forms, consisting of cast-off epithelia, tartar and bacteria. The 
breath has now become extremely foul and exceedingly characteristic 
of its mercurial origin. Ulceration now begins under the pultaeeous 
deposit. The ulcers have a yellowish or greenish flow of lardaceous 
quality and are surrounded by a broad, bright-red areola. Ulcers 
also appear here and there upon the mucosa of the mouth and tongue. 
The entire mucosa swells, the cheeks receive the impression of the 
teeth, the tongue may attain such size that the mouth cannot be closed. 
Even in the worst cases there may be portions of gum l^ft intact. In 
the severe cases the patient naturally presents symptoms of general 
hydrargyrism. In individuals "w^ith good teeth and mouth care the 
only lesions may be a few scattered ulcers on the cheeks and tongue. 


The mercury may be received into the system in any of the pos- 
sible ways. Cases from the therapeutic use seldom occur to-day, for 
a variety of reasons, and all measures are taken to prevent this acci- 
dent. In the industrial arts there is also prophylaxis, but cases are 
il occasionally reported in looking-glass makers, bronze workers, etc. 


The tenderness of the gums on striking the teeth together and the 
peculiar breath odor should suffice for a correct diagnosis. 


Plate 58. 
















The most scrupulous asepsis of the month must be observed, with, 
of course, cessation of exposure to mercury. The mouth should be 
irrigated with solutions of boric acid, hydrogen peroxide, or chlorate 
of potassium. In very severe cases, iodoform should be applied in 
any efficacious manner between the gums and cheeks. 

Fig. 91. Model in Finger's Clinic in Vienna (Hennmg). 


Dyschromia Gingivae Saturnina 

Plate 58, Fig. 92 

This condition is the ''lead line" which forms on the gnms in sub- 
jects affected with saturnism. Plumbers and other workers in lead 
develop as one phase of poisoning with the same, stomatitis with 
gingivitis and swelling of the mucosa almost wholly confined to the 
margin of the gum. In this locality fine particles of metallic lead or 
lead sulphide are deposited, the clinical result being the line in ques- 
tion. This is bluish-gray or bluish-black in color. The patients are 
often unaware of its existence. The breath has a peculiar character- 
istic odor. The lead reaches the mouth through the salivary glands, 
which may inflame. The lead line has great diagnostic significance. 


The management of lead poisoning in general is indicated, 
together with antiseptic mouth washes. 

Fig. 92. Model in v. Bergmann's Clinic in Berlin (Kolbow). 


Plate 59. 

Fig. 93. Miliaria rubra. 

Miliaria Rubra 

Synonyms: Lichen tropicus, Prickly heat 

Plate 59, Fig. 93 

This eruption consists of inflammatory miliary vesicles and pap- 
ules at the mouth of the sweat-follicles. The small clear vesicles 
representing occluded sweat-pores may become inflamed so that some- 
times a complex state results. The affection occurs during intense 
paroxysms of sweating, producing a characteristic prickly sensation 
added to ordinary itching. The covered parts in which radiation is 
most difficult, suffer chiefly. In some individuals prickly heat is 
most apparent after cooler weather succeeds great heat. Profession- 
ally it is seen in workers at high temperatures who drink beer or 
even water to excess. Strophulus is a local miliaria occurring only in 
infants on the surfaces which are naturally warmest. 


The trouble is caused by excessive heat and the wearing of heavy 
underwear. It is most common in obese subjects, especially in those 
overheated by injudicious eating or drinking. 


The recognition of this affection is seldom difficult, although at 
times it may suggest acute vesicular eczema. 


Cooling diuretics and laxatives with a light diet afford the quickest 
relief. Sedative lotions and dusting powders relieve the pruritus 
and with the removal of the causal factors the eruption soon 

Fig. 93. Model in Neisser's Clinic in Breslau (Kroener). 


Folliculitis Barbae 

Synonym: Sycosis non-parasitica 

Plate 60, Fig. 94 

This affection is not to be confounded with ringworm of the beard, 
which is sometimes termed parasitic sycosis. Since eczema, when it 
attacks hairy localities, shows a tendency to suppurate from acci- 
dental infection with pyogenic microorganisms, it might at first sight 
be assumed that foUiculitus barbae is only an eczema of the bearded 
area. This, however, is by no means the case, for a similar purulent 
folliculitis may occur in any area covered with hair. The scalp is 
rarely attacked, save at its borders. The eyebrows may be involved 
and sometimes the pubes and axillae. It is not recorded that a 
generalized folliculitis of all the hairy integument can occur in a 
single subject. The opposite tendency is more in evidence and even 
in a preferred locality, like the beard and mustache; the disease is 
often limited to definite areas. In some instances, as in sycosis of 
the middle of the upper lip, the predisposing or exciting cause is 
connected with a discharge from the nostrils. In other cases the 
affection seems to take root in a particular locality and travel from 
follicle to follicle by local infection. The degree of suppuration, the 
amount of scarring and obliteration of follicles, and the presence or 
absence of keloidal scarring all combine to characterize individual 


Folliculitis barbse is regarded at present as due to the entrance of 
ordinary pyogenic staphylococci into the follicles of the beard and 
elsewhere. In certain cases pus does not form, so that only a papular 
folliculitis occurs. The reaction to the disease varies greatly with 
the individual. Infiltration about the follicle may be slight or exten- 
sive. It was formerly taught that the hairs of the beard were not 
loosened by the disease, but this sometimes occurs. Some patients 
seem naturally disposed to loss of substance and scarring ; so much 
so that a grour> disease of necrotic foUiculitides may in time be 


Plate 60. 















To distinguish between ringworm of tlie beard and sycosis is of 
first importance and this is readily done by epilation and examining 
the hairs for fungi. 

It is very difficult to differentiate radically between eczema limited 
to the beard, etc., and sycosis, the chief marks of distinction being 
largely academic. Sycosis does not itch much, and a drop of pus may 
be squeezed from a follicle. 

Pustular acne may also be mistaken for sycosis, but in acne the 
pustules are larger and there is generally other evidence of sebaceous 

Some of the lesions of syphilis may at times resemble sycosis. 
The pustular syphiloderm which might be mistaken for sycosis is 
never confined to the face alone and the late papular tubercular 
syphilide, which might be limited to one region, would seldom be 
symmetrical, as in sycosis. The lesions would be larger, less acutely 
inflammatory, and would not exhibit the pustular points surrounding 
the hair-follicle. 


As in folliculitis from other causes the disease is naturally very 
chronic and refractory to treatment. It is very difficult to destroy 
the organisms in the follicles. 


The beard must be clipped short, for the irritation caused by the 
growing hair is great. Soothing applications are then indicated until 
the patient is able to shave. This is practically as beneficial as epila- 
tion, an old resource. The patient is now placed upon mild antiseptic 
ointments, white precipitate or sulphur usually having the preference. 
If the face is considerably irritated an ichthyol or diachylon ointment 
may be substituted. In chronic cases good results are often obtained 
by the use of X-rays. Autogenous vaccines are probably of more 
value in folliculitis barbae than in any other cutaneous affection. 

Fig. 94. Model in Freiburg Clinic (Johnsen), 

Acne Varioliformis 

Plate 60, Fig. 95 

The resemblance of this affection to variola lies only in the scars, 
for the lesions are of very slow evolution. The expression acne 
varioliformis has also been applied for years to molluscum contagi- 
osum; so that in some quarters the term folliculitis varioliformis is 
used. The lesions, discrete papulo-pustules, occurring on the face, 
naturally resemble an acne, but show a special tendency to occur on 
the forehead, especially along its hairy border. They also extend well 
into the hairy scalp and this fact alone serves to differentiate the 
affection from ordinary acne. Another important point is the absence 
of comedones and of anything like free suppuration. The pus in the 
centre of the pustules cannot be squeezed out, and this is not due to 
any perifollicular location, but only to the fact that the central core 
is not really pus but a yellow slough. This forms and separates very 
slowly and the loss of tissue is replaced by a depressed scar or pit. 
Although the lesions are chiefly discrete they sometimes occur in small 
groups. Some individual lesions may be as large as a bean, and if a 
number of large lesions are closely aggregated there is at times a 
marked resemblance to syphilis. 


The affection is rather rare and little is known as to its intimate 
nature. Those who do not believe in the individuality of so many new 
diseases incline to regard this affection as a tuberculide. 


The differential points of common acne have already been outlined 
— location, character of pustule, etc. The Wassermann reaction 
should help distinguish it from syphilis. 


The disease is an obstinate one, and also tends to recur, but is 



Applications must be made to penetrate into the follicles with a 
view of preventing new lesions. The integument should first be pre- 
pared with a salicylic acid ointment, after which sulphur, ammoniated 
mercury, naphthol, resorcin or other bactericide appears to be suflS- 
cient, with patience, in removing the affection. 

Fig. 95. Model in Neisser's Clinic in Breslau {Kroener). 


Acne Vulgaris 

Plate 61, Figs. 96 and 97 

This affection, nominally almost peculiar to the sebaceous glands 
of the face with a slight tendency to extend over the shoulders may 
exceptionally occur thickly over the upper two-thirds of the back, in 
which situation its relationship to these glands is much less apparent. 
In certain individuals acne may also occur on the limbs, nor is there 
any evidence that these subjects are notably in poor general condi- 
tion or uncleanly. The incidence of the disease upon the face is 
readily explained by the prominence of the sebaceous glands in this 
locality, the patent state of the outlets and the tendency for these to 
become obstructed from "within or ^\•ithout. Acne, however, is much 
more than a mere obstructive affection, for in the worst lesions the 
chief mischief occurs and may begin outside of the follicles. Dermic 
abscesses often form on the face and back, some of these being quite 
extensive, and deep pits result which sometimes resemble those of 
smallpox. Nor in cases where these lesions occur is there any evi- 
dence that the process necessarily began with obstruction of the se- 
baceous outlets. Treatment directed to cleansing the skin and open- 
ing the pores may not be able to avert the formation of these 
perifollicular lesions. For these and other reasons an attempt was 
long made to distinguish radically between acne vulgaris, the obstruc- 
tive type of acne of the face and acne indurata, occurring on the face, 
shoulders and back alike, and consisting essentially of perifollicular 
suppuration. At the present time this distinction is only made from 
the clinical standpoint, as it is impossible to state where one begins 
and the other ceases. 

Acne vulgaris in the narrow, clinical sense can often be traced 
step by step. Beginning wath a plugging of a sebaceous duct, the 
lesion is then kno-wn as a comedo or black head. The first evidence 
of follicular reaction, as shown by the formation of a reddened papule, 
is termed acne papulosa, or pimples. As a matter of fact, however, 
the papules of acne very often represent pustules which have been 
evacuated. When pus forms in the centre of a papule, as a result of 


Plate 61. 







infection within the latter, the condition constitutes an ordinary acne 
pustule or pimple which has come to a head. Large papulo-pustules, 
slow of evolution, which do not come to a head, and which often do 
not discharge any pus, represent a deep-seated inflammatory process 
which involves a group of sebaceous follicles. In certain cases pus 
either does not form at all, or becomes encysted ; so that nodules may 
persist in the skin for weeks, or until fresh suppuration occurs. In 
some of the larger lesions several foci or pus may form, and these 
may coalesce to produce a large cavity. In many cases the dermic 
abscesses behave like the cold abscesses of scrofulous subjects and 
occur in patients of a marked scrofulous habitus. 

Acne is essentially a multiform affection in which comedones, 
papules, small pustules and perifollicular abscesses may occur side by 
side. Certain cases never pass much beyond the comedo stage, and 
many have no other lesions than comedones and small papulo-pus- 
tules. It by no means follows that the latter do not scar, for they 
often produce fine pits; but these tend in time to become hardly 
perceptible. A characteristic feature of acne lesions is that they are 
disseminated quite uniformly. Although there appears to be no good 
reason why many contiguous follicles do not become involved to- 
gether, it is a fact that acne lesions do not coalesce to form large 
patches. We have already seen that some coalescence of perifolli- 
culitis is necessary to produce the large indurations and abscesses. 
Acne tends to come out in successive crops or continuously, and there 
is a considerable relation between the character and duration of the 
lesions. Small papulo-pustules may go and come quickly, larger ones 
have a much longer cycle. The indurated lesions which cannot be 
evacuated may persist for weeks. Acne on the back seldom bears any 
relationship to acne of the face. The latter may show but few lesions 
in a patient whose back is densely covered. 


The tendency of an acne to begin about puberty and to disappear 
spontaneously within a number of years, shows the presence of a 
marked developmental element. Acne depends so closely on so many 
different factors that these must be regarded as elements, which, how- 
ever dissimilar, all tend to make the follicles a culture medium for 
various pathogenic germs. The number of dietetic articles which may 
determine acne in different individuals is very large. For each pa- 
tient there are a few classes of food or single articles which cause the 
breaking out, and it is not impossible that anaphylaxis is responsible. 


Otherwise it is hard to understand how in some subjects, nuts, cheese, 
etc., always appear to deternoine new lesions. The claim was once 
made that a dilated stomach is largely responsible for acne lesions, 
and that if this underlying condition is treated properly much benefit 
results. Constipation is often clearly associated with the formation 
of comedones and intestinal autointoxication due to constipation is 
also a factor. Menstruation is often sufficient to produce a number of 
papulo-pustules which run their course rapidly. The part played by 
microorganisms is very evident, but the disease is not contagious and 
it is doubtful if it is even autoinoculable. 


Acne vulgaris may be confused with iodic and bromic pustules. 
The only actual disease which may simulate it is the papulopustular 
syphUide, and this shows certain groupings and does not spare any 
area, while acne does not occur in the eyebrows or on the eyelids. 


Acne vulgaris is often very hard to control during the first years 
of its existence, but after puberty is well over it responds better to 


The treatment of acne is both general and local, and to be of per- 
manent value should be continued faithfully for a long time. 

General treatment consists of hygienic, dietetic and medicinal 
measures calculated to improve the physical condition of the patient. 

Cold bathing or sponging, as much out-door exercise as the pa- 
tient's strength permits of, with regular hours for eating and sleep- 
ing, should be insisted upon. Late hours, especially with late suppers, 
are injurious, and all foods liable to cause gastrointestinal fermenta- 
tion should be avoided. It is always advisable to impress the neces- 
sity of this firmly upon the patient. Fried greasy food, rich soups 
and gravies, and pickles and cheese should be eliminated from the 

For the gastric fermentation the following rhubarb and soda mix- 
ture will be found serviceable : 

5 Pulv. rhei 3i 

Sodii bicarbonat 3iii 

Aquae menth. pip 5"* 

M. et ft. Sig. — Teaspoonful after meals. 


If there is atony of the stomach-walls, 3ii of tincture of nux vomica 
can be added to the above ; and if constipation is also present, 3ii to 
3iv of the aromatic fluid extract of cascara sagrada can be added also, 
or the cascara can be given in the form of tablets at bedtime. 

In plethoric patients Bulkley recommends : 

19 Potassii acetatis 3vi 

Tinct. nuc. vomica 3ii 

Ext. cascara sagrada fl 3ii 

Ext. rumex fl ad Jiii 

M. et ft. Sig. — Teaspoonful in water one-half hour before meals. 

Anemia must be treated with iron and arsenic tonics. The elixir 
of iron, quinia and strychnia is a valuable preparation, and the follow- 
ing will be found exceptionally good: 

^9 Ferri et ammoni. citratis 3i 

Liq. potassi. arsenitis 3i to 3ii 

Liq. potassias 3i to 3ii 

Tinct. nuc. vomica 3ii 

Tinct. gentian comp Ji 

Aquae ad "^w 

M. et ft. Sig. — Teaspoonful in water after meals. 

Where constipation with anemia exists, the following modification 
of Startin's mixture is excellent: 

^ Ferri sulphatis 3i 

Magnesii sulphatis 3iv to Ji 

Acidi sulphurici diluti, 

Syrupi zinziberis aa 3iv 

Aquas ad Jiii 

M. et ft. Sig. — Teaspoonful in glass of water after meals. Take 
through a tube. 

This is especially good in the indurated type with large 

The local treatment of acne is very important. 

All comedones should be removed mechanically and the pustules 
opened ; this hastens the cure and lessens the scarring. This should 
always be done by the physician and never left to the patient. 

The face should be washed in cold water only and no soap should 
be used. Steaming the face and using hot water leaves the pores 
dilated and increases the tendency to comedone formation. 

The plan used so much abroad of using peeling ointments is seldom 


advisable. It can be used occasionally on the forehead when large 
numbers of blacklieads are present; but its use must always be 
followed by the regular routine treatment described below. 

The following ointment causes desquamation. It should be spread 
thickly over the part to be peeled and allowed to remain in place for 
about an hour, then removed with dry cotton. This is repeated daily 
for three or four days. 

^ Betanaphthol 9ii 

Pulv. sulphur precip 3iv 

Saponis mollis, 

Paraffini mollis aa 9v 

M. et ft. Sig. — Scaling paste (Lassar). 

When dermatitis develops water must not be used, but a bland 
dusting powder or a soothing lotion can be applied to relieve the feel- 
ing of tension and burning. After desquamation has begun a mild 
ointment such as cold cream or boric acid ointment can be used. 

The best results are obtained by the use of lotio alba, to which 
three per cent, of precipitated sulphur is added. 

IJ Pulv. sulphur precip., 
Zinci sulphate, 

Potassii sulphuret aa 3i 

Aqua? rosas ad '^iv 

M. et ft. lotio. 

The potassium sulphuret should be fresh, as it changes on ex- 
posure, and the lotion made from an old article is practically useless. 

As the skin becomes tolerant, the strength of the lotion can be in- 
creased three or four times. This is to be applied thickly night and 

When the skin is very oUy and the pores become clogged easily, it 
is advisable to apply the above at night and use the following in the 
morning, rubbing in well: 

^ Pulv. sulphur precip Si 

Etheris sulphurici 5iv 

Spr. vini rect ad §iv 

M. et ft. lotio 

Occasionally the patient's skin will not tolerate the above, espe- 
cially in the beginning of the treatment. In these cases the following 
modification of the Kummerfeldt lotion is useful: 


^ Pulv. sulph. prep 9 ii i 

Camphori gr. vi ] 

Pulv. acaciae 9 i 

Aquas calcis 3iv 

Aquffi rosas ad ^iv 

M. et ft. lotio 

Seborrheic dermatitis of the scalp frequently accompanies the 
acne, and this must be treated. For this condition the following lotion i 

is very good : 


^ Hydrarg. bichlor gr. i ; 

Resorcin 3ii - 

Spr. vini rect 3iv 

Aquae rosae ad 5'^ > 

M. et ft. lotio i 

If this makes the hair too dry, a small amount of glycerine, 3i to 
3ii, may be added to the lotion. | 

Vaccine treatment in acne has proven very disappointing. i 

Trimble, in a large series of cases at the New York Skin and Cancer 
Hospital, had generally unsatisfactory results. 

Figs. 96 and 97. Models in Neisser's Clinic in Breslau (Kroener). 


Acne Rosacea 

Plate 62, Fig. 98 

In tliis affection there are acne lesions of a peculiar type plus a 
condition of dilated blood-vessels. Both classes of lesion are due 
to persistent flushing or congestion of the face and seldom appear 
until after the period in which developmental acne has run its course. 
The vascular or hyperemic element gives the lesions a peculiar, angry 
look. In young subjects pustules on or beside the nose may present 
this angry appearance, but there is never any general outbreak. 
These rosaceous papules and pustules come and go very rapidly and 
suppuration plays a much smaller part than in other common forms 
of acne, the typical lesions being macules, papides and tubercles. 
Pus formation is usually limited. 

The manifestations of this affection differ greatly, for the two ele- 
ments may be combined in many ways. The mildest type is confined 
to the nose, perhaps only to the tip, and is present as a mere intense 
redness, paling on pressure. The lesion may be due to a pustule from 
an occluded gland in which case it usually quickly subsides when the 
pus escapes. Much more commonly is the red area on the nose a 
simple congestion without any glandular implication, and which tends 
to persist for an indefinite period. The lack of an acne element in 
these cases induces some authors to make a distinction between mere 
rosacea and acne rosacea, but the dependence of both lesions on a com- 
mon cause is indisputable. Thus the pure rosaceous type is very 
commonly associated with oily seborrhea. The entire nose may be 
bright red in color without any acne element associated. The redness 
comes and goes and in the course of time permanent telangiectases 
appear. Redness and oiliness may involve the entire face and is a 
matter of physical habit or complexion rather than an actual disease. 
In these sMns the sebaceous glands are prominent and are often seen 
to be the seat of comedones. Small, scattered telangiectases are seen 
here and there. In another type of skin which is finely grained and 
free from any predisposition to disorder of the sebaceous glands a 
naturally florid skin becomes with advancing years a network of telan- 


Plate 62. 

Fig. 98. Acne rosacea. 

Fig. 99. Rhinophyma. 

giectases which may reach down upon the neck and involve the ears. 
This type shows clearly that rosacea may be entirely distinct from 
acne or seborrhea and result from constant congestion. 

The diffuse type of acne rosacea is well marked. Certain individ- 
uals after a few days' excessive use of liquor and tobacco, which ordi- 
narily produce a simple flushing of the face, may break out suddenly 
over the entire congested area with acne rosacea. It may appear with 
almost the suddenness of a rash, the entire face and forehead being 
covered with macules and papulopustules. There are no selective 
areas. These cases soon subside with removal of the cause, but if the 
latter continues in action the condition becomes steadily aggravated. 
The varying element of predisposition is seen in the fact that not all 
men who use alcohol have congestion of the face and of those who do, 
only a small minority develop acne rosacea. 

The most typical form of acne rosacea is diffuse with a tendency 
to develop in a special area, to wit, the forehead, middle of the face 
and chin. In bald people it may be noted that the lesions on the fore- 
head may extend upon the scalp. Acne rosacea seldom appears before 
the age of thirty, and it will very often be found that these subjects 
have suffered from juvenile acne and sometimes the latter passes 
directly into the other form. These patients show combinations of 
acne and rosacea. The nose may be the seat of the latter alone, while 
the papules show a certain tendency to be aggregated into circum- 
scribed patches on the lower portion of the forehead, centre of the 
cheeks and chin. This form is essentially chronic or recurrent, due to 
deep-seated causes. 

In chronic acne rosacea a type of lesion appears which is not seen 
in acne vulgaris and which is doubtless a consequence of the pro- 
tracted congestion. This is a superficial tubercle or nodule, which 
evidently represents a hypertrophy from excess of nutriment. While 
it may occur wherever there is a focus of disease, its higher degrees 
are almost peculiar to the nose. 


Aside from the palpable effects of alcohol the causal elements are 
obscure. Occupation is seen in the rosacea of cabmen, resulting from 
prolonged exposure to cold with sudden transition to hot rooms, and 
the free use of alcohol. The rosaceous element greatly preponderates 
over the acne in these. Most of the factors which determine and 
aggravate acne vulgaris may be seen in acne rosacea. Chief of these 
are digestive disorders and menstrual irregularities. In a number 


of my cases it has occurred to me that the acne was more or less 
related in its etiology to pyorrhea alveolaris. The rosacea seen in 
hale old men often indicates defective metabolism incidental to ad- 
vanced age and inability or disinclination to change their mode of 


In rare cases in which eczema attacks the acne area a distinction 
may be impossible at first. Acne rosacea, however, does not itch and 
the skin may be cooler than normal. A hj'perplastic circumscribed 
patch of acne may closely simulate lupus of either form or a syphUide 
but no real confusion should arise here. 


The prognosis with full and proper management is good for recov- 
ery and the chance of spontaneous recovery or recovery under half 
measures is correspondingly poor. 


The regulation of the diet and habits is the same as that required 
in acne vulgaris. In addition the digestive organs may benefit by 
direct treatment of the indigestion which often seems far more in 
evidence than in acne vulgaris. The services of a dental surgeon are 
often indicated and in refractory cases a gastro-enterologist may 
render much service by making an exact diagnosis of the state of the 
digestive organs. 

Saline purgatives and other derivative and depletive measures, 
provided they do not flush the face, often accelerate the reduction of 
the congestion of the face. In some cases no impression is made on 
the disease untU aU causes of flushing are eliminated. Thus hot 
drinks and hot soup at meals have to be forbidden. The frequent 
occurrence of rosacea in dressmakers seems due to a combination of 
causes which have this tendency, as drinking much hot tea, improper 
posture, sewing for hours in front of a hot lamp, etc. 

In some cases considerable benefit follows the internal use of 
ichthyol. This should be given after meals in doses of from ten to 
twenty grains, either in capsules or well diluted in water. 

Not much can be accomplished by local treatment, aside from sur- 
gical measures, beyond the constant use of a protective sediment- 
lotion. The most serviceable application is strong lotio alba. When- 
ever the seborrhoic element is very marked, resorcin is specially 


In well-developed forms, much may be done by various instru- I 

mental resources — scarification of densely congested areas, elec- j 

trolysis of telangiectases, etc, with hot applications to encourage j 

bleeding and promote the slow circulation. Hydrotherapy appears ' 

to exert a favorable influence in restoring the tone of the vessels. j 


Fig. 98. Model in Neisser's Clinic in Breslau {Kroener). 



Plate 62, Fig. 99 

This condition has been termed the third stage of acne rosacea, but 
it is best regarded as an independent affection. It is nearly always 
confined to males and as the name implies is limited to the nose. Were 
it actually the extreme stage of acne rosacea we should expect it to 
develop more frequently. As a matter of fact, however, the affection 
is a very rare one and may occur in men who have previously had but 
little acne. So far from being a mere hypertrophy or hyperplasia, 
there is said to be a new formation of fatty tissue. The affection 
behaves in every way as a neoplasm, growing to an almost indefinite 
extent with a tendency to lobulation and the production of pendulous, 
more or less pedunculated lobes at the dependent portion. The his- 
tologic picture is a variable one. There may be found aU stages of 
inflammation, capillary dilatation, hypertrophy of the sebaceous 
glands, as well as granulation and cicatricial tissue. 


The only treatment is surgical. The lobulated and thickened por- 
tions should be removed and the underlying tissue pared do\\Ti to the 
cartilage. Healing is prompt and the results are generally satis- 

Fig. 99. Model in Neisscr's Clinic in Breslau {Kroener). 


Plate 63. 









Dermatitis Papillaris Capillitii 

Synonym: Acne-Keloid 

Plate 63, Fig. 100 

Not much is known of this peculiar affection beyond the fact that 
it is limited to the nuchal region at the scalp border, a locality prone 
to folliculitis and furuneulosis, and that it often depends on persistent 
irritation of the neckband. The earliest lesions bear a considerable 
resemblance to those of sycosis barbae when the latter forms nodes and 
tubercles ; but there is no evidence that the present affection is a fol- 
liculitis. As in sycosis, raw papillary outgrowths appear and form 
crusts. The infiltration which causes the nodules and the prolifera- 
tion at the surface are attended with a sclerotic and cicatricial 
tendency, the latter having a disposition to form a scar keloid. The 
lesions are densely aggregated at the nucha, and the various changes 
which take place tend to cause atrophy and destruction of the follicles. 
This is offset by a tendency of the process to extend upward along the 
occiput. The keloidal element is regarded as characteristic of this 
affection, and sufficient to distinguish it from any form of folliculitis, 
acne or furuneulosis. 


The diagnostic points have already been outlined. Confusion with 
any other affection is hardly possible. 


For a benign affection its course is singular, persistent and re- 
fractory to treatment. 


Improvement in nutrition and withholding of irritation do not 
exert a beneficial influence. Cleanliness, epilation and mild antisepsis 
produce surface improvement only. Destruction by cautery and even 
excision of the diseased area have been followed by recurrence. 
Improvement often follows the protracted use of the X-rays. 

Fig. 100. Model in Freiburg Clinic (Johnsen). 


Granulosis Rubra Nasi 

Plate 63, Fig. 101 

This affection was not described until 1900 by Luithlen. Jadas- 
sohn named it, and made the first important contribution to the 
literature, reporting a considerable number of cases. It is believed to 
stand in necessary relationship with sweat-glands, so that it ranks 
in this respect with hyperidrosis and other functional anomalies of 
these organs, miliaria and sudandna and hydrocystoma ; also with 
various diseases in which the sweat-glands appear to be involved sec- 
ondarily. The affection appears to be peculiar to the face and largely 
restricted to the nose. Exceptionally it may extend from the latter 
and involve the upper lip or cheeks. 

Clinically, it is a form of red nose, which, however, has nothing 
in common with acne rosacea, and which, moreover, is almost or 
quite peculiar to young children, who seldom or never suffer from 
the other malady. Hence a red nose in a child or a yoimg adolescent 
should suggest this possibility. Despite the diffuse redness, the 
affected skin is seen to be the seat of papules, which remain discrete, 
although placed close together. The individual lesions do not exceed 
the size of a pinhead, and are bright red or brownish red in color, 
paling readily on pressure. It could hardly be confounded with 
seborrhea, but resembles to some extent both forms of lupus. There 
is no reason for regarding it as a tuberculide. The affection is one 
eminently chronic, but destined to be outgrown during late adoles- 
cence. It therefore has a developmental element. Thus far the 
subjects have been delicate children in the second period of childhood 
— from seven to fifteen years. Hyperidrosis often coexists both in the 
affected skin and elsewhere, and is regarded as part of the predis- 
position. The occasional presence of hydrocystoma also adds 
strength to this view. The individual papules appear to undergo 
some central suppuration and desiccation. Neither scars nor stains 
are left. Little or nothing is known of the intimate nature of the 
affection, and no successful remedies have yet been recognized. 

Fig. 101. Model in Neisser's Clinic in Breslau (Kroener). 


Alopecia Areata 

Plate 64, Fig. 102 

This affection is that form of baldness in spots which is not due to 
any known form of parasite nor secondary to any other known 
affection. Our conception of it is negative rather than positive. 
The fact that it may develop with relatively acute symptoms and 
involve all or several of the hairy regions of the body is sufficient 
to distinguish it from all ordinary local forms of baldness. There 
is no essential difference between alopecia areata and the universal 
shedding of all the hair which may occur in general diseases and after 
profound nervous impressions. This fact, combined with much other 
evidence, seems to point to other than merely local causes of alopecia 
areata. On the other hand, well-known fungi can produce baldness 
in spots, and this, with other evidence, points to a parasitic origin of 
at least certain cases. Many authorities therefore speak of two 
separate forms of the disease. Aside from the unicistic and dualistic 
viewpoints, a compromise view is possible. We may suppose the 
cooperation of constitutional or nervous influence weakening the soil, 
and a germ of low pathogenicity able to act upon such a soil. 

Alopecia areata was evidently well known to antiquity and under 
such names as area Celsi and ophiasis receives rather more descrip- 
tion than other more important affections. Ophiasis is commonly 
spoken of as referring to a serpiginous or creeping form which 
denudes the scalp in bands or sinuous tracts. It is, of course, barely 
possible that the name comes from the shedding of its skin by the 

As already implied, the skin itself undergoes no change, and in 
the frequent absence of any efficient causes the spontaneous char- 
acter of the process suggests something foreordained to occur. The 
identity of the circumscribed and diffuse types is paralleled by the 
alopecia due to syphilis. As a rule, the loss of hair is confined to 
circumscribed areas, comparable in size and shape to prints of the 
finger-tips. Exceptionally there is relatively rapid loss of hair in 

In a very few instances an epidemic incidence of this affection has 
been noted. While at first sight this seems conclusive evidence of 
contagion, the wholesale occurrence of disease may be due to other 
factors, especially those able to act upon the ductless glands. 


In the majority of cases patients present themselves "nith bare 
spots on the scalp, and a history of sudden or more insidious shedding 
of the hair. After a lock of hair has been shed, the hairs at the 
margin continue to come away until as a rule self-limitation occurs. 
Hence the greater the number of the primitive spots, the greater the 
likelihood of extensive baldness. In certain cases, however, the 
process may extend in a straight or sinuous band, and the balance of 
the scalp may or may not be involved. In a third type the baldness 
caimot be said to occur in spots, for the hair of one-half of the scalp 
may be shed almost en masse. In still another type the marginal 
shedding of the hair about the early bald spots may not be arrested, 
but may persist until all the scalp hair is sacrificed. It is thus seen 
that there are several ways in which the scalp may be largely or 
fuUy denuded. 

In some of the more acute, diffuse cases of alopecia of the scalp, 
shedding of the eyebrows and eyelashes may also occur. This compli- 
cation need not indicate a general disposition to shedding of the hair, 
because the innervation of the eyebrows is the same as that of part of 
the scalp. This is also true of cases in which the beard is involved. 
But there are cases of total loss of scalp hair in which the face is un- 
affected. In true alopecia universalis the axillary, pubic, and all the 
scattered hairs over the surface may be shed. One of the most char- 
acteristic features of alopecia areata in general is the well-marked 
tendency of the hair to grow in again at some more or less remote 

The eyebrows and beard are sometimes involved without the scalp, 
and in the former, by reason of their limited area, the different 
varieties of shedding may all be studied. In some cases the hair is 
simply thinned out, without formation of spots. In others a spot 
forms and the rest of the eyebrow remains intact; or the spot may 
spread imtU the brows are denuded. There may be an irregular 
combination of small irregular spots and thinning which causes an 
eroded or moth-eaten look. Finally, the hairs may be shed suddenly 
en masse. There is no doubt that all these modes of shedding occur 
in the scalp and elsewhere. Therefore the initial bald spots are not 
necessary steps in the development of the disease but only the 
commonest step. 

When patients with alopecia areata present themselves late in the 
evolution of the disease decided attempts at regeneration of the hair 
may be noticeable. An old, self-limited patch may be the seat of a 
downy growth, or pigmented bristle-like hairs may be sparsely pres- 


ent. In certain cases opportunity is afforded to see the shedding of 
this second growth. 

A pertinent question refers to whether or not cases of apparent 
parasitic or internal origin exhibit any differences in symptom- 
atology. This question does not seem to be answered fully by authors 
and but little data are available for this purpose. 


The association of certain cases of alopecia areata with psychic 
and nervous factors is unquestionable and a long series of examples 
is given by all systematic writers. It is to be feared, however, that if 
all such cases could be added together they would make only a small 
fraction of the total material. There is also much variation among 
these psychoneurotic factors. Some are examples of psychic shock, 
and it is not a simple matter to connect this factor with the innerva- 
tion of special areas of the scalp. In physical injury the psychic 
element is doubtless paramount, but there are not a few cases which 
have followed various injuries of the scalp itself. In a few instances 
alopecia areata has been seen as a familial disease, which almost 
amounts to a demonstration of some sort of transmissible inferiority 
or biological anomaly. The best-marked examples of a neurotic 
factor are those in which a direct or reflex disturbance of innervation 
may be inferred. Eye strain and dental lesions, particularly the 
former, may be mentioned here as possible causes. On the other 
hand, anomalies of the hair, eyes and teeth may be associated together 
on developmental grounds. In certain cases, however, the crucial 
test of treatment seems to point to the presence of a neurotic factor. 

At the other end of the etiologic scale may be mentioned the 
parasitic element. In a relatively small percentage of cases this 
seems to be imdoubted or probable. The few accounts on record of 
epidermic incidence point in the same direction. The dilemma which 
confronts us is whether to assume that all cases are parasitic, on 
the one hand, or to attempt to isolate a special contagious form of 
disease. Of the two the latter seems to be the safer course. For 
the past seventy years, or almost as far back as clinical microscopy 
extends, authorities have claimed the discovery of the parasite of 
alopecia areata. At present it is evident that no one microorganism 
can be accused. There is much evidence in favor of any one of three 
or four kinds, including bacilli, cocci and fungi, the latter indistin- 
guishable from the ringworm fungi. Several observers assert that a 
slight inflammation of the corium is always at the bottom of alopecia 
areata ; in common with other obscure affections, the latter has been 


attributed to a periarteritis or thrombosis of the nutrient blood- 


Alopecia areata has to be distinguished from all other forms of 
baldness in spots and in fact baldness of any sort. Ordinary baldness 
begins as a bare spot on the crown and a localized loss of hair on the 
temples high up. Some of the symptoms are much the same, for 
example, shedding of hair on the pillow, etc. The only lesion of an 
alopecia areata may chance to be on the crown. Both forms are under 
general and nervous influence to some extent, and in both there may 
be attempts at regeneration, although in ordinary premature bald- 
ness these are practically never successful. In ordinary premature 
baldness we may isolate certain types "which have nothing in common 
with alopecia areata, but there is a residue of cases in which this 
separation is not so easily effected. Much that would be termed 
alopecia areata represents a gradual thinning or a copious irregular 
shedding, and some cases show no tendency to regeneration ; so that 
we are forced to ask if premature baldness may not begin at times 
as alopecia areata. In sj-philitic alopecia the bald spots are smaller 
than those of alopecia areata, and other sjTnptoms of syphilis are 
generally present. 

There remain for consideration only the bald spots due to kno-ftTi 
parasites — the trieophyton. This may sometimes denude the scalp 
cleanly of hair. In such cases hairs at the margin of the bald spots 
should come away readily and show the presence of parasites. 
Secondary baldness from destructive lesions and wounds should be 
readily recognized, for the follicles have been obliterated. 


There is quite a pronounced tendency to spontaneous regenera- 
tion, especially below a certain age limit, which is placed at about 
forty years. This is offset, however, at times, by the inferior char- 
acter of the second growth, which may also faU out anew. In cases 
of prompt, complete regeneration, we are once more reminded of a 
physiologic shedding of the hair, or rather of an occurrence in brief 
time of a process which goes on normally more or less imperceptibly. 
On the other hand, ordinary premature baldness may perhaps 
appear as alopecia areata, and in such cases no regeneration is to be 
expected. Prognosis should be guarded, but encouraging the patient 
■will lead him to take pains with the treatment, and the prognosis 
with good treatment is naturally much improved. Extensive, rapid, 
generalized alopecia, especially after the age of forty, gives a bad 


prognosis. Patency of follicles and presence of downy hairs are of 
good prognostic significance. Blistering a small area in a bare spot 
win sometimes cause the sprouting of a tuft of good hair. This test 
is usually a good prognostic, although it cannot be relied on 


As in any affection with an inherent tendency to self-limitation 
and regeneration, numerous plans of management and individual 
remedies have gained an ill-merited reputation for curative proper- 
ties. If the hair is still being shed it is well to use constitutional 
measures, tonics and nerve stimuli. Arsenic, phosphorus, nux 
vomica, iron, piloearpin, etc., one or several, may be pushed and the 
various electric currents may be employed. On the same general 
principle errors of refraction should be corrected with proper glasses, 
carious teeth be filled, etc. On the supposition that a parasite is 
involved, the patient must be protected from auto- and heteroinfec- 
tion. The scalp should be washed frequently with parasiticides, and 
the patient should use only his own set of combs and brushes, which 
should be kept clean. 

The actual direct treatment consists of stimulating the scalp to 
secure a new growth of hair. The stimulating remedies may also 
figure as parasiticides, so that the double indication may be filled 
with a single prescription, one, for example, containing sulphur and 
Betanaphthol. This plan is for the entire scalp, but for the individ- 
ual bald spots, especially when the latter are of some age, intensive 
local treatment is indicated. This also applies when a large area of 
denuded scalp or the entire scalp is involved. 

While applications of every grade of severity, short, of course, 
of destroying the follicles, have been employed for this purpose, it is 
doubtless best to apply at the outset one of the stronger remedies — 
chrysarobin in full strength, pure carbolic acid, tinct. cantharides, 
tinct. capsicum, corrosive sublimate, oil of turpentine, etc. The de- 
sired effect is vesication. Cantharidal collodion, equal parts tinct. 
cantharides and glycerine, pure carbolic acid, pure lactic acid are effi- 
cacious. One good application should be sufficient. A period of about 
two weeks is required for the sprouting of new hairs. Excellent 
opportunities are offered for control studies, as several vesicants 
may be tested simultaneously. The local treatment of alopecia areata 
is resolved practically to using a succession of the most efficacious 
vesicants, going from one region of the scalp to another. 

Fig. 102. Half-tone, Dr. Kingsbury, of New York. 


Alopecia Congenita 

Synonyms: Alopecia adnata, Hypotrichosis, Universal congenital atrichia 

Plate 65, Fig. 103 

Congenital alopecia, a very rare condition, is characterized by a 
partial or total absence of hair at birth, or a short time thereafter. It 
is occasionally accompanied by defective development of the teeth 
and nails. The hair loss may be patchy in character, or the hair 
growth scanty and marked by the appearance of lanugo hairs or dowTi. 
The eyebrows, and later in life the axillae or pubes, may, or may not, 
be affected. Many individual cases of so-called hypotrichosis are 
seen at a very late period, and it is then not always possible to 
exclude an early infection of the scalp, with secondary hair loss. 
Occasionally nail dystrophy is the most important feature, the hair 
being involved to a less extent. Defective development of the teeth 
may exist in all gradations, from a few misshapen and irregular teeth, 
to total edentation. Other abnormal conditions, sometimes associated 
with hypotrichosis, are diminished or abolished secretion of tears 
and sweat. 


The condition is due to a congenital anomaly in the development 
of the hair pouch from the epiblast, and heredity is the most impor- 
tant factor in its causation. The disease has frequently been traced 
through several generations in the same family. Nicolle and Ealipre 
knew of no less than thirty-six cases of hair and nail dystrophy in 
six generations. In the three cases illustrated (Fig. 103), the 
maternal grandfather had the same disease. The father of the ma- 
ternal grandfather was said to have been bald all of his life and 
two of his brothers were also absolutely devoid of hair. 


Alopecia areata, which at times may resemble it, begins later in 
life, occurs in roimd or oval, well defined areas, which soon show 


evidence of the return of hair. Even when complete, there is a 
history of its beginning in areas. 


This is unfavorable in the great majority of instances. 


Any underlying constitutional disturbance should be corrected. 
The local treatment should be of a stimulating character. 

Fig. 103. Half-tone, Dr. Kingsbury, of New York 



Synonym : Leucoderma 
Plate 66, Fig. 104 

This affection represents a disappearance of pigment in patches 
■with a tendency to increase peripherally. Just external to the patch 
there is usually an increased deposit of pigment, so that the affec- 
tion is rather a dyschromatosis than a mere atrophy. VitUigo is 
neither to be confounded "with congenital absence of pigment, nor 
with secondary loss of the same. 

The disease tends to appear not only on exposed regions but also 
on the trunk. In the black race, the peripheral hyperpigmentation 
is seldom noticeable. The spots, rounded in contour, enlarge and 
coalesce. The skin is otherwise absolutely xmchanged. The hairs — 
eyebrows, for example — usually turn white when involved in a patch, 
but in some cases remain unchanged. In certain cases a peculiar 
illusion is produced, as when the affection has extended over an entire 
area, save a few islets of normal skin. Here the white color may 
seem the normal shade, while the normal skin imposes itself as 
chloasma or some similar pigment anomaly. This illusion is not 
uncommon in a very chronic case of vitiligo on the backs of the 
hands, which is a favorite seat for the affection. 


The affection is evidently very deepseated. It is common in dark 
races, and may be inherited. Mixture of race may conduce to it, 
although some of its extreme manifestations occur in pure-blooded 
negroes. Psychic shock, nerve injuries and local irritation appear 
to have initiated the process in a few cases. It is claimed that the 
pigment is originally increased before it disappears. This would 
account for the outlying pigmented zone. 


The affections which might cause confusion have in part been 
mentioned. If there is any confusion with chloasma, or other dis- 


Plate 66. 







coloration, the presence of the scalloped convex border of vitiligo 
will usually dispel it. In leper countries, and especially among 
dark races, vitiligo is often confused -with leprosy, especially so as 
non-pigmented patches often occur in anesthetic leprosy. Syphilitic 
leucoderma, so-called, occurs on the neck, and nearly always in 


The affection, while progressive, seldom or never becomes imi- 
versal. Not only is its march very slow, but it eventually ceases. 


Arsenic, nux vomica, phosphate of zinc and other nerve tonics are 
recommended on theoretical grounds. The only satisfactory local 
treatment consists of cosmetic measures designed to diminish the 
contrast between the patches and the normal skin. 

Fig. 104. Model in Neisser's Clinic in Breslau {Kroener). On the abdo- 
men there are two urticarial wheals. 



Plate 66, Fig. 105 

While this term is used somewhat as a synonym for hyperpig- 
mentation in general, it is best restricted here, as it is in the clinic, 
to a single condition known as chloasma uterinum, this being a 
definite, common and well-characterized affection. In passing, it 
may be stated that hyperpigmentation is due both to external and 
internal causes. The former class include all darkening of the skin 
from exposure to the weather, and from chemical, thermal, and 
mechanical irritation. The latter, also termed symptomatic, include, 
besides chloasma uterinum, many forms of pigmentation from gen- 
eral diseases, especially Addison's disease, malaria, and cachexise in 
general, and from certain drugs, as arsenic. 

Chloasma uterinum, so-called, is, as the name implies, peculiar to 
women, and especially to pregnant women. It is usually limited to 
the face, and much more pronounced in brunettes. Exceptionally it 
is seen on the trunk and limbs. On the face, the site of choice is 
the forehead, and in non-gravid women it is often limited to that 
region. It sometimes covers the entire face, as "ndth a mask, and 
this is perhaps oftener seen in pregnancy, or at least the "mask of 
pregnancy" is a common expression. The lesions occur naturally in 
small irregular blotches, with a strong tendency to become confluent. 
The color varies from yellowish to deep broAvn, and in the less marked 
degrees is hardly distinguishable from freckles. The affection does 
not involve the epidermis, the skin being of normal texture. 


The appearance of chloasma in the gravid woman is usually con- 
nected with the deepening in color of the areolae of the nipples and 
linea alba. From this view^joint it should be almost physiologic. 
Others regard it as a mild manifestation of the toxemia of pregnancy. 
But since it often accompanies uterine and ovarian diseases in the 
non-gravid, it may also be called a reflex, although the rationale is 


unknown. Finally, it occurs in women not known to have utero- 
ovarian disturbance, and is then attributed by the laity to biliousness. 
From the fact that it is peculiar to women, and women during the 
menstrual cycle, and that it appears in pregnancy to vanish after 
delivery, and also stands in a similar causal relation to utero-ovarian 
diseases, it evidently stands in intimate association with the repro- 
ductive cycle. In women the affection may exceptionally be almost 


On its usual site, the face, chloasma could hardly be confounded 
with any other discoloration except chromidrosis. In other localities, 
unless also present on the face, diagnosis might prove very difficult. 
It might be necessary to exclude various other pigment anomalies and 
stains. For confusion with vitiligo, see account of the latter. 


Although chloasma in the gravida disappears with the cause, this 
is not necessarily the case with chloasma in the non-gravid, although 
it is common enough, especially when the discoloration appears to 
stand in close relationship with some pelvic lesion. Wlien no such 
relationship is in evidence there may be no tendency to disappear. 


The management comprises, first, attempts to remove the cause — 
for example, ovarian dysmenorrhea. The other resource, which is 
purely cosmetic, is removal of the discolored cuticle by vesicants. 
Not all the pigment may come away, but the balance will probably 
be absorbed. However, the trouble may readily recur. Of various 
preparations used as vesicants may be mentioned corrosive sublimate 
in 5% aqueous solutions, saturated solution of salicylic acid in 
alcohol, and salicylic acid collodion. 

Fig. 105. Model in the Freiburg Clinic (Johnsen). Ninth month of 



Naevus Vascularis 

Synonyms: Nsevus sanguineus, Port-wine mark — Mother's mark 

Plate 67, Fig. 106 

These differ radically from nsevi vernicosi in being neoplastic, 
the latter ranking only as hypertrophies. Technically they are angio- 
mata of various types with the exception of the telangiectases, which 
are usually held to be acquired as the result of long-continued conges- 
tion, active or passive. The number of clinical forms is very 
considerable. In some cases large naevi are present at birth upon the 
head or face, and on account of the disfigurement are often removed 
at a very tender age. They may grow rapidly and become pulsatile. 
In certain instances they disappear of themselves. There is some 
danger of injury, hemorrhage, infection and sloughing, also of certain 
regressive changes. The second familiar type is the port-wine mark, 
a flat formation having a red or livid hue. These birth marks differ 
greatly in size and shape and coloration, hence their supposed resem- 
blance to strawberries and other objects and their supposed depen- 
dence on maternal impressions. 


Beyond the possibility that these formations have an embryonic 
origin, but little is known of their intimate nature. An alternate 
view is the dependence on amniotic adhesions. 


These neoplasms should be readily recognized. 


If the tumor is growing rapidly or is pulsating, the possible out- 
come has already been alluded to. The mother's mark form does not 
undergo any changes. 


Small angiomata may be destroyed by carbonic acid snow, radium 
electrolysis or chemical caustics. Large growths are usually treated 


Plate 67. 

Fig. 106. Naevus vascularis. 

Fig. 107. Naevus linearis. 

by operating surgeons. Port-wine marks are usually treated with 
electrolysis, but this does not cause the total obliteration of the mark, 
the latter only paling somewhat. Good results are sometimes 
obtained by the use of carbonic acid snow. 

Fig. 106. Model in Freiburg Clinic (Johnsen). A girl, seventeen years of 
age, with an enormous navus flammeus covering nearly the entire half 
of the body, and leaving but little healthy skin. 


Naevus Linearis 

Plate 67, Fig. 107 

While this type does not differ much in structure from naevus 
verrucosus, there is often a special development of the horny layer. 
In other cases the warts of which it consists have a discrete papillary 
formation which closely simulates an eruptive affection. The chief 
characteristic of the linear naevus is the close agreement of its area 
of distribution wdth that of the cranial or spinal nerve for the 
area. This causes them to assume a linear or rather band-like outline 
upon one half of the body. The nature of this localization is by no 
means apparent. A neurogenous theory is not necessary, for it may 
be shown equally that the naevi follow the metameric segments, 
embryonic sutures, lines of skin cleavage, etc. In other words, the 
mischief has evidently been done before the nerves have been differ- 
entiated. As a rule these formations are extensive, occupying half 
the face, or neck, etc. 


Chemical caustics are often employed for the removal of the 
growths, but better results may be obtained by the use of the sharp 

Fig. 107. Model in Neisser's Clinic in Breslau (Kroener). 

Plate 68. 

Fig. 108. Naevus papillaris pigmentosus. 

Naevus Papillaris Pigmentosus 

Plate 68, Fig. 108; Plate 69, Fig. 109 

Most writers make a special group-affection known as nsevus 
pigmentosus, which they subdivide into flat, hairy and warty types. 
The two first-mentioned appear to represent abortive forms in wliich 
the new formation is limited chiefly to the pigment cells and hairs. 
The resulting hypertrophy is simply a flat, smooth pigmented disk of 
variable size, with or without the presence of a certain number of 
bristle-like hairs. In the verrucous form, on the other hand, the 
entire thickness of the skin may be involved in the hypertrophy, 
especially the papillary layer of the corium. The pigment cells and 
hair usually participate, so that a large or small, warty, uneven 
patch is formed, almost always pigmented and piliferous. If the 
connective tissue participates the growth usually contains much fatty 
tissue, and may hang loose upon the skin. The favorite localities for 
all these overgrowths are the head and face, neck and upper part of 
the trunk. As a rule the particular area involved appears to possess 
no special significance, although an exception must be made of the 
linear, unilateral type. Aside from this type the formations may 
vary greatly in size, shape and number, and no laws can be laid down 
for their distribution. They may be of the finest size or may occupy 
the entire shoulder area. 


As a rule they are spoken of as congenital, although not neces- 
sarily actually present at birth. There can be but little doubt as to 
their embryonic origin. 


These overgrowths are absolutely typical and can never be 
confused with any other condition. 


They attain a certain growth and have no tendency whatever to 
disappear. In rare cases they form the starting point for malignant 
melanotic tumors (Fig. 109), 



Wide excision is the most satisfactory treatment, as the possibility 
of malignant degeneration is thereby discounted. This, however, is 
often impracticable, for several reasons. Small moles may be re- 
moved by caustics or electrolysis, the latter also being indicated to 
destroy the grovrth of hair. For extensive formations, it may be 
necessary to proceed piecemeal, levelling the surface with curved 
scissors, and cauterizing the exposed surface. 

Fig. 108. Model in Neisser's Clinic in Breslau (Kroemr), 
Fig. 109. Model in v. Bergmann's Clinic in Berlin (Kolbow). 


Plate 69. 













Adenoma Sebaceum 

Plate 69, Fig. 110 

This rare affection is classed with new growths to-day, although 
at one time it was placed among the nsevi, of which it was supposed 
to represent a papulovascular type. It develops from the sebaceous 
glands of the face, its highest development occurring at the sides of 
the nose. The new growths, varying in size from a pinhead to a 
small pea, are very numerous and closely aggregated. They are 
either devoid of special color or are red or broAvn in hue, these 
shades depending on a vascular or pigment component. They are 
congenital, although not necessarily visible at birth. Like all con- 
genital hypertrophies or neoplasms, their appearance may be delayed 
for years. They may be associated with other malformations and the 
patients are generally of a low grade of mental development. 


These lesions may simulate a number of affections, especially of 
the sebaceous glands — acne rosacea, multiple benign cystic, epithe- 
lioma, moUoscum contagiosum, and colloid milium. It should, 
however, be possible to exclude all of these without much difficulty. 


This affection is well adapted to electrolysis. Another resource 
is the production of exfoliation by any vesicating application. 

Fig. 110. Model in Neisser's Clinic in Breslau {Kroener). 


Ichthyosis Simplex 

Plate 70, Fig. Ill 

Essentially a hypertrophy of the horny layer of the epidermis, 
this condition also represents a defect because of the abolition of 
the cutaneous secretions. It is not certain whether the latter is due 
to pressure atrophy or whether both atrophic and hj'pertrophic 
features belong to a single dj^strophic condition. Ichthyosis simplex 
may be present in varj-ing degrees, and the overproduction and char- 
acter of the scales often suggest the skin of a fish or reptile. The 
sjTnptomatology, therefore, varies with the case, to such a degree that 
different cases may resemble one another but slightly or not at aU. 
In the very mildest form the skin feels and appears dry and does 
not perspire. The hair-foUicles may form small firm papules on the 
upper arms, thighs, etc., giving the appearance of permanent goose- 
skin. Such integument has been Likened to a nutmeg grater. The 
condition is similar to that seen in lichen pilaris, an affection which 
can exist without ichthyosis. This degree of the disease is character- 
ized by slight desquamation. A prominent feature is that it is not 
much in evidence in warm weather, but returns again with the 
approach of wTnter. Hence remedies may be believed to have cured 
eases which improved spontaneously. '\^lien skins of this sort are 
treated with inunctions of oUy matter, they may appear natural for 
the time. In these mild cases the regions of preference are the ex- 
tensor surfaces of the extremities, but unnatural dryness may be 
made out on the back and elsewhere. In cases of higher degree a 
tilelike arrangement may be noted, corresponding in part to the 
natural folds of the thickened skin. However, there is also a cleavage 
in the opposite direction, so that the skin is mapped out into poly- 
hedral areas, suggesting strongly a retrogression to the fishes and 
reptiles. In the highest degrees of hypertrophy of the scales, there 
is some tendency to the formation of fissures, while the low vitality 
appears to predispose to other affections. 



Ichthyosis is eminently a congenital affection, as shown by occa- 
sional familial incidence, and doubtless originates at an early period 
of intrauterine life. 


Well-developed ichthyosis simplex is unmistakable. But mild de- 
grees are readily confounded with other kinds of dry skin, inherited 
or acquired. The history of ichthyosis, when one is obtainable, will 
be sufficient — appearance in early childhood, improvement in warm 
weather, etc. 


As a deformity, ichthyosis may exceptionally in mild forms be 
outgrown. It may be kept down by treatment. Otherwise it is 
incurable. - 


The skin must be kept soft, all accumulated scales to be first 
removed. Alkaline baths, soap and salicylic acid all conduce to the 
latter end. The best emollient is probably glycerole of starch, 
although lanolin should be valuable. Of specific remedies, sulphur 
and resorcin have been praised. 

Fig. 111. Model in Freiburg Clinic (Johnsen). The transitions from the 
slightest grade of Ichthyosis simplex to the fully developed Ichthyosis 
serpentina are beautifully rendered in this picture. 


Ichthyosis Hystrix 

Plate 71, Fig. 112 

This affection is regarded by some authorities as an advanced 
degree of ichthyosis simplex, but such a view seems hardly tenable, 
because of the localized character of the alterations, -which often have 
a purely Uneal grouping. However, the two forms are often seen 
side by side, and in some severe types of ichthyosis simplex a few 
of the lesions of hystrix appear here and there; while on the other 
hand this apparent unity of nature is shattered by cases in which the 
severest forms of hystrix appear on smooth, supple skin. In this 
type of cases we are reminded irresistibly of linear nsevi of an 
unusually horny quality, and the histological examination shows 
practically no indifference between hystrix warts and ordinary 
acquired verrucae vulgares. 

Like ichthyosis simplex, hystrix occurs in various degrees, types, 
shades of color, etc. When the lesions are very acuminate, they 
suggest the spines of a porcupine ; when flattened, they are likened 
to the bark of a tree, etc. Hystrix does not properly occur in large 
diffuse sheets, and if this alteration is present, as when an entire 
foot and ankle are involved, the condition is usually classed under the 
severest type of ichthyosis simplex. Linear hystrix shades imper- 
ceptibly into a group of affections in which hypertrophy of some of 
the cutaneous structures is often associated with the distribution of 
one or more spinal nerves. 


While clinically by no means the same condition, whatever has 
been said concerning the congenital nature and histology of ichthyosis 
simplex wiU apply in a measure to hystrix, although in the latter the 
structure of common warts is parallel, i.e., the rete is involved 
in proliferation as well as the horny layer, and tends to dip into 
the interpapillary spaces, while the papUlae show more or less 


Plate 71. 


' ■•^? 

;»■■,* , 




^ i 







This is summed up in a few words. The horny masses must be 
dissolved by strong alkaline solutions (liquor potassae) or strong 
salicylic acid ointments. The hypertrophied papillse must now be 
destroyed by curettage or caustics, and if the patient does not object 
to the scarring which in time follows this practice, the prognosis is 
notably better than in ichthyosis simplex. 

Fig. 112. Model in Freiburg Clinic (Vogelbacher). Very pronounced cast 
of Ichthyosis hystrix. Palms and soles are strongly involved. 


Ichthyosis Congenita 

Plate 72, Fig. 113 

This affection is very rare, and not all cases so termed deserve 
this title, for they simply represent exfoliation of the skin of the 
newly born from other causes. That ichthyosis congenita is of little 
practical significance well appears from the fact that such children, 
often prematures, usually perish within a short time. The affection 
is one of fetal life, and at birth the integimient is hopelessly involved 
and has even undergone marked retraction, so that ectropion occurs 
and the condition of the mouth makes nursing impossible. The 
thickened epidermis fissures in various directions and the peculiar 
appearance has caused the patient to be termed "harlequin fetus." 
The condition is not to be confused with one characterized by an 
unusual quantity of hardened vernix caseosa which cracks in a similar 
manner. The subjacent skin in this condition is normal, save that 
the fissures may sometimes involve it to some extent. However, 
unless promptly removed by inunctions, the deposit may lead to the 
death of the newly born by interference -with nutrition and thermo- 

Fig. 113. Model in Neisser's Clinic in Breslau (Kroener). 


Plate 72. 











Keratosis Pilaris 

Synonym: Lichen pilaris 
Plate 72, Fig. 114 

This affection represents an hypertrophy of the corneous layer of 
the epidermis about the hair-follicles. The regions involved are 
confined largely to the backs of the arms and outer, posterior aspect 
of the thighs. The papules are skin-colored, reddish or darkish, and 
are often transfixed by a broken hair. They are closely studded 
together, but not grouped, suggesting the prominences on a nutmeg- 

Lichen pilaris is hardly a disease in the ordinary sense of the 
word, but a deformity. It may be confused with goose-skin, a transi- 
tory affection produced by muscular spasm, and patients may consult 
physicians for cosmetic reasons. In its mild forms it is by no means 
uncommon. Like ichthyosis, it begins to be conspicuous in cool 
weather, and is at its best in summer. 


It seems to be a feature of a preternaturally dry skin, such as is 
usually congenital, but may come about from actual disease or from 
too much use of soap and water. 


This is seldom difficult, although the affection has doubtless been 
confused with lichen scrofulosorum and pityriasis rubra pilaris. 


This depends largely upon the attention given to treatment. 


Frequent bathing in warm water is indicated, and the use of 
green soap and a rough wash cloth generally removes the horny 
plugs. Anointing the skin with a bland oil or fat at the time of 


bathing is useful. The following is an agreeable and effective oint- 
ment for this purpose : 

IJ Acidi carbolici 9i 

Boroglycerini 3ii 

Lanolini ^ 

Ungt. aquie rosae Jiii 

M. et ft. ungt. 

Fig. 114. Model in Neisser's Clinic in Breslau {Kroener), 


Plate 73. 


1 J 











Fibroma Molluscum 

Synonyms: MoUuscum fibrosum, Molluscum pendulum 

Plate 73, Fig. 115 

This term is applied alike to one or a few of the soft pedunculated 
tumors of the skin, to the massive lesions which form a clinical type 
of elephantiasis, and to a generalized fibromatosis in which the entire 
surface may be more or less thickly covered with tumors of various 
sizes. The growths have to attain a certain size before they can hang 
down, so that all below a certain size are sessile, and project but little 
beyond the surface. The pendulous property, however, is dependent 
on something besides the weight of the mass, for the size of the 
attachment is all important. The broader the latter the less the 
tendency to hang down. Conversely, a very minute tumor with a 
narrow insertion will hang down. In generalized fibromatosis nearly 
all of the tumors are sessile. There is both a tendency to grow and to 
be arrested, as shown by the great variation in size. The large ele- 
phantiastic tumors usually appear on the head or neck, otherwise the 
trunk is the favorite locality both when lesions are few and when they 
are numerous. 


This affection is to be regarded as a deformity rather than a 
disease. It may run in families, and its nearest congeners are other 
benign tumors, such as lipomata and neuromata. They do not 
destroy life, but may cause great discomfort and incapacity when very 
large or numerous. 


In certain cases arsenic appears to have some influence in decreas- 
ing the size of the tumors. The larger tumors should be removed 
by excision or ligature. 

Fig. 116. Model in Lassar's Clinic in Berlin (Kasten). 


Dermatomyoma Multiplex 

Plate 73, Fig. 116 

This is a rare affection, the diagnosis of which can only be 
established fully vrith the microscope. It is a multiple benign neo- 
plasm, composed in part of smooth muscle fibres. A variable amount 
of fibrous tissue is associated, so that in certain cases fibromyoma is 
the proper designation. The tumors are seated for the most part on 
the limbs and may be discrete, but are usually grouped. Their color 
varies from that of the skin to pink, red and reddish-brown. They 
do not exceed the size of a pea, are firm, somewhat flattened, round 
or oval, and in some cases quite painful. Most subjects who present 
these lesions are adidt females. The causes are entirely tmknown, 
and the debut is insidious. A probable diagnosis can be made from 
the color and the subjective sensations. These growths never become 
malignant, and never ulcerate or undergo any notable degree of 
degeneration. They sometimes disappear spontaneously. 

In addition to the multiple form, solitary myomata also occur in 
the scrotum, vulva and nipples. These may attain a considerable 
size. The only treatment for dermatomyomata is excision. 

Fig. 116. Model in collection of Prof. Touton in Wiesbaden. 


Fig. 117. Verrucae vulgarcs. 

Fig. lis. Papillomata (condylomata acuminata). 

Verruca Vulgaris 

SynonjTn : Common warts 

Plate 74, Fig. 117 

These represent a circumscribed hypertrophy of the papillary 
and epidermic layers of the skin, and are invariably acquired, 
although similar to congenital warts in structure and appearance. 
They may be flat or pointed, have a wide sessile base or be filiform 
with narrow attachment. They occur by preference on the hands, 
but also are common on the soles of the feet, between the toes, etc. 
In these localities they are related to ordinary corns and callouses 
and have the same causation. These callous warts occur much more 
infrequently than corns and callouses. A third locality for warts to 
develop is the scalp, where they may be very numerous. Common 
warts of the hands sometimes appear to have a primary lesion or 
mother wart, from which others develop. They may be very numer- 
ous, and sometimes become aggregated to form a large mass. 


Warts on the hands, which constitute a well-marked clinical 
variety, are almost peculiar to the young, when they appear in crops. 
Isolated warts are seemingly of a different nature and may result 
from mechanical irritation at any period. Warts apparently arise 
from inoculation and autoinoculation. They may come and go 
rapidly, despite the fact that there is a much greater disposition to 
appear slowly and remain stationary. When warts are removed from 
one hand they sometimes disappear from the other. We know nothing 
as to the contagious element, but it should resemble that of molluscum 
contagiosum. A long incubation period is required, measured some- 
times by weeks and even months. The microbic cause should operate 
by an ordinary irritation. 


Common warts can hardly be confounded with anything else; 
but since certain forms of irritation of the skin may cause a wartlike 

growth, it may be well to bear this fact in mind, for different proc- 
esses, even epithelioma, begia as ordinary warts, although late in 


A tendency to warts is believed by some to yield to a course of 
arsenic, others advise the administration of repeated doses of sul- 
phate of magnesia. 

Various forms of local treatment are recommended : surgery, elec- 
trolysis, caustics, and keratolytic applications. The high frequency 
spark is often effective but it is always exceedingly painful and on 
the whole the more primitive therapeutic measures are to be pre- 
ferred. The application of a twenty per cent, salicylic acid plaster 
or of salicylic acid in collodion (3ss to 3ii) softens the horny part 
of the wart and greatly facilitates its removal "\Adth the sharp curette. 
Touching the base with the nitrate of silver stick will generally 
prevent recurrence. Nitric acid should not be used as it sometimes 
produces keloidal scars that are quite as disfiguring as the original 

Fig. 117. Model in Neisser's Clime in Breslau {Kroerter). 



Synonym: Condylomata acuminata 

Plate 74, Fig. 118 

These are the so-called venereal or gonorrheal warts which have 
no relationship with any other form. They are virtually peculiar to 
the mucous and cutaneous surfaces of the genitals of both sexes, but 
could doubtless occur in any locality under precisely the same condi- 
tions. Thus they have been seen on the thighs at considerable 
distance from the genitals, and even in the axillse and navel. No 
precise causal agent has ever been isolated, least of all the gonococcus. 
Were the latter the cause it would not be easy to account for the high 
degree of immunity often seen. The contagious, autoinoculable na- 
ture of these warts may be seen in the evolution of the latter; as 
when, for example, they develop in the anus after the latter is exposed 
to the secretions of warts in the vulva. The warts may be dry or 
bathed in a contagious gonorrheal secretion. 

They usually appear on the inner side of the prepuce and glans, 
as the characteristic thin, pointed coxcomb-like vegetations, and on 
the corresponding regions in the female. There may be only a few 
warts or they may be so numerous and confluent as to produce strik- 
ing deformity. In the male we may see paraphimosis develop, while 
in women the entire vulva may be so covered with them as to occlude 
the vaginal entrance. One of my first obstetrical cases as a medical 
student occurred in a woman suffering from this condition to a 
marked degree and I still retain a vivid recollection of the very 
protracted second stage of that particular labor. 


It is unknown how far this affection has a special contagious prin- 
ciple and whether it passes directly from one sex to the other, or only 
through the medium of gonorrhea. 



The only affection with which these warts could be confounded 
is hypertrophic mucous patches. The term cauliflower excrescence^ 
has been applied to high degrees of each kind/but practically belongs 
to the former. The association of the two processes is perhaps 
responsible for this confusion. ,i| 

Treatment m 

MUd cases usually subside rapidly under cleanliness and a strong J 

astringent like glycerotannin. In higher degrees the warts are much I 

firmer and more highly organized, so that surgical measures are 
usually required. One of the most common plans is excision with 
scissors followed by the application of the galvano-cautery to the 
base. Some authorities seem to regard this as unnecessary and prefer 
to use strong caustics like nitric acid, applied in serial sessions. 



Fig. 118. Model in Freiburg Clinic (Johnsen). A servant girl, nineteen 
years of age. Gonorrhea not established. 

160 ! 

Plate 75. 

Fig. 119. Verrucae seniles (cavernomata senilia). 

Verruca Senilis 

Synonym: Senile warts 

Plate 75, Fig. 119 

The seborrheic warts which appear in the elderly are sometimes 
accompanied by another type of senile new-growth, the cavernomata. 
These are really small angiomata, the papular capillary varices of 
old people. Aside from their occurrence in late life, wherein they 
resemble telangiectases, they may be considered in the same class of 
growths as ordinary angiomata. These lesions, like the seborrheic 
warts, are most frequently situated on the chest, abdomen and back, 
often very abundantly about the shoulders. The latter lesions some- 
times show a bandlike management (Fig. 119). They vary in size 
from a quarter of an inch to one inch in their long diameter. At first 
they are light brown in color, but later they become gray or brownish 
black. The surface is scaly and slightly granular. 


There should be no difficulty in recognizing either the verruca or 
the cavernomata. 


The possibility of malignant degeneration should be borne in 


As the verruca are quite superficial, the best results are obtained 
by the use of the sharp curette. The cavernomata should be excised 
or left entirely alone. 

Fig. 119. Model in Neisser's Clinic in Breslau (Kroener). On the lower 
part of the back is a carcinomatous tumor in course of development. 


Keratosis Senilis 

Plate 76, Fig. 120 

This condition is most commonly seen on the back and face in 
middle-aged and elderly subjects. In these they present different 
features from the flat warts in children, o'vsang to their peculiar 
covering. The verrucous part is flat or slightly papillomatous, and 
covered by a dark sebaceous or horny crust. The lesions seem inter- 
mediate between warts and moles. In size they range from a split 
pea to that of a finger-nail, and may be single or multiple. In many 
cases they appear to represent the earliest stage of an epithelioma. 
If the crusts are detached they at once reform. The diagnosis should 
be easy, save for the question of a possible beginning epithelioma. 


These formations yield readily to the X-rays. It is better treat- 
ment, however, to curette or excise the growth. 

Fig. 120. Model in Freiburg Clinic (Vogelbacher) . On the upper lip and 
on the cheeks several incipient small epitheliomata, which yielded 
promptly to X-ray treatment. 


Plate 76. 














Xeroderma Pigmentosum 

Plate 76, Fig. 121 

This affection, first recognized and named by Kaposi (1870), is a 
very rare and eminently familial malady, which may be roughly 
characterized as a congenital defect of the skin that simulates the 
ordinary senile integument, and undergoes changes seen in the latter 
with a special tendency to malignant degeneration. An important 
question relates to the identity of the atrophic, hypertrophic and 
degenerative changes of this affection with the same lesions occurring 
under more familiar circumstances, and the consensus of opinion 
answers in the affirmative. In infancy and early childhood it is only 
noted that the patients have a thin, dry skin which freckles easily 
and is easily irritated. Macular atrophy and telangiectases develop 
later. In the course of years, perhaps much earlier, the freckles are 
seen to be undergoing changes into flat pigmented naevi and verruca?. 
Retraction of the skin has been slowly taking place until ectropion 
develops with perhaps contraction about the nostrils and mouth. 
Eventually the naevi and warts become the seat of malignant degen- 
eration. The ordinary freckle area is the one involved in this 


This affection could not be mistaken for another save perhaps in 
its earliest stages. 


The outlook is highly unfavorable. Exceptionally the period of 
malignant degeneration may be so deferred that the patient dies 
from some other disease but practically he is doomed to a lingering 
death by marasmus. The individual lesions do not menace life as is 
usually the case with epithelioma. 


This is entirely expectant and symptomatic. 

Fig. 121. Model in St. Louis Hospital in Paris, No. 1464 {Baretta). 

Quinquaud's case. 


Keratosis Follicularis 

Synonyms: Darier's disease, Psorospermosis 

Plate 78, Fig. 122 

This rare affection, first recognized by Barter in 1889, belongs 
among the hypertrophies of the corneous layer and in its Inception 
bears some resemblance to the lesions of lichen pilaris. As the 
papules increase in size they are seen to contain a sort of sebaceous 
core. At the outset they are discrete, but later they tend to form 
patches composed of individual lesions which never exceed a large 
pinliead in size. Beginning as a rule on the face and head or less 
commonly on the hands, they develop very slowly, the lesions becom- 
ing thicker and more confluent, while new localities are successively 
attacked. Preferential regions are the sternum, loins and genito- 
crural folds. Lesions may also occur on the extremities. With age 
the sebaceous plugs may become horny. In some cases the accumu- 
lations distend the follicles; and the resulting cavities may become 
transformed to secreting ulcers. 


Darter believed it to be of parasitic origin, but this view has been 
rendered imtenable. The affection is decidedly familial, although not 
to the extent that some are, for the majority of cases are of solitary 
incidence. It is not manifest at the early age of most of these presimi- 
ably congenital affections, for in most cases it developed in adoles- 
cence. Still a few began in infancy. Histologic studies appear to 
show that we have to deal with errors in keratinization — a para- 
keratosis. This error is probably a deep-seated one, dating back to 
the developmental period, but perhaps not manifested ordinarily 
until the later development of the pilosebaceous system. The affec- 
tion remains throughout a very superficial one, the corium suffering 
no notable changes. 


So few cases are known that not much can be said in regard to 
possibilities of diagnostic confusion. In theory the latter might 


Plate 78. 

Fig. 122. Keratosis follicularis. 

arise in reference to other forms of lichen before the disease had fully 
developed, especially lichen pilaris. Again it possesses some resem- 
blance to moUuscum contagiosum in that both affections have a 
central, removable core. In fact, Darier believed the two to be 


There appears to be no tendencies to self-limitation or to spon- 
taneous recovery. Tendency to degenerative change may exist, as 
showTi by the development of epithelioma in one case, but this was 
perhaps a mere coincidence. The general health does not become 


The disease cannot be cured, for it is too deep-seated ; but it can 
be benefited notably and by reason of its disagreeable character and 
the disfigurement it requires vigorous management merely from the 
cosmetic viewpoint. The management is similar to that of ichthyosis, 
the concrements being cleared off with weak caustic alkalies and 
salicylic acid applications. The X-rays may produce benefit and 
there is some room for minor surgery in destroying the follicles. 

Fig. 122. Model in Freiburg Clinic (Johnsen). 

Elephantiasis Penis et Scroti 

Plate 78, Fig. 123 

The prepuce is highly disposed to edema, so that frequently recur- 
ring inflammation appears to close up the lymphatics and cause a 
stationary edema, -which in the course of time results in a thickening 
of the skin and subcutaneous tissues. The constructive nature of this 
process is apparent from the fact that in extreme cases aU subjacent 
tissues participate. In such cases the integument may appear smooth 
and intact or be the seat of ulcers and papillary outgrow'th. 

It is common to consider this condition along "vs^ith elephantiasis 
of the face, limbs, etc. In other words, there is often a single process 
underlying all these forms. While in temperate zones vre cannot lay 
bare any single factor, in elephantiasis in the tropics we find a special 
cause in the filaria sanguinis which is able unaided to cause elephan- 
tiasis of the penis and scrotum. 


The diagnosis of the condition presents no diflSeulties. 


This varies according to the cause. 


TSTien produced by the filaria sanguinis the treatment is naturally 
for that condition. In chronic cases satisfactory results sometimes 
follow ablation of the hj'pertrophied tissue. 

Fig. 123. Model in Cochin Hospital in Paris (Jumelin). Mauriac's case. 


Plate 78. 

Fig. 123. Elephantiasis penis et scroti. 

Plate 79. 







Plates 79 and 80, Figs. 124, 125, 126 

This is probably a general affection, which is manifested chiefly in 
the skin. The weight of evidence upholds the view that the earliest 
manifestations are in the blood-vessels, and that an angioneurotic 
element is also present. An initial stage of edematous infiltration is 
soon followed by atrophy and shrinking of the skin, which as a result 
becomes hidebound. 

The affection manifests itself under three very different clinical 
forms, which, while closely related and often occurring side by side, 
are known by different names, and have been and still are, held by 
some to be different affections. Occurring in small circumscribed 
patches, the disease has always been known as morphea, and the 
peculiar discolored appearance — yellowish, bluish, pinkish, etc. — with 
its border of dilated blood-vessels, and its ultimate atrophy, causes it 
to resemble greatly a patch of skin in lepra anesthetica, and it has 
even been regarded as an anomalous form of that affection. How- 
ever, there is no anesthesia, nor does morphea as a rule occur with 
any definite relation to a sensory nerve. The lesions of morphea may 
occur on the face, trunk or limbs. Diffuse scleroderma, or sclero- 
derma in the narrower sense, may occur in a number of scattered 
localities, or occupy a large portion of a limb, or may cover the 
greater part of the surface, even to becoming universal, in which 
case the patient becomes, as it were, mummified. "WTien the entire 
face and neck are involved, the result is called the sclerodermatous 
mask. The mucous membranes may be attacked. The third form of 
the disease — sclerodactylia — attacks the digits, extending for some 
distance centrally. This expression of the disease, especially in its 
typical isolated form, is ranked with the acroneuroses, because the 
trophic element is very pronounced. Not only do the fingers become 
hidebound, but the bones and joints may undergo involutional 
changes and ulcers may result. 

The general form of the disease may run an acute course with 


general sjanptoms resembling those of acute rheumatism. The 
edematous stage is well marked in such cases, and often results 
promptly in atrophy. As a rule, however, the disease begins insidi- 
ously, is chronic when first noticed, and while edema is absent there 
is considerable infiltration, which may not show atrophic changes for 
a long period. The acute type of lesion not infrequently imdergoes 
spontaneous involution. The tendency of the disease is to incapaci- 
tate the subjacent organs. In the limbs the muscles atrophy from 
pressure and disuse, and in some eases are directly attacked by the 
disease. The joints are inmiobilized, the thorax impeded in its 
movements, the emotions are no longer expressed, chewing and 
swallowing are interfered with. 


Only in a few cases is there any conclusive relationship between 
effects and causes, and such cases do not agree among themselves. 
The apparent rheumatic nature of certain cases is of no help in 
explaining the affection, and although a positive Wassermann reac- 
tion is sometimes obtained, it is generally believed that the disease 
is in no way related to sjT)hilis. Further speculation on the nature 
of the affection is unprofitable. 


The resemblance of morphea and sclerodactylia to other affec- 
tions, already cited, is evident ; but diffuse scleroderma can hardly be 
confused "w^th any other condition save perhaps in its stage of 
edema and infiltration, when it has been taken for myxedema. 


Owing to the fact that some cases improve and even recover 
relatively without aid the benefits of treatment are naturally open to 
doubt. Time is an important factor. The patient should be guarded 
against cold, and residence in a warm climate is desirable. Internal 
treatment is of little avail except when directed to improvement of 
the general health. For this purpose ferruginous tonics, codliver oil, 
strychnia, quinia, and occasionally arsenic are useful. Pilocarpin 
properly supported b}' a stimulant has been recommended. Thyroid 
extract has strong advocates as weU as disappointed experimenters. 
In extensive cases it is at least worthy of trial. A few of my cases 
were apparently slightly benefited by the use of potassium iodid. 
Hehra has reported good results from the intramuscular injection 


every second day of ten minims of a fifteen per cent, solution of 
thiosinamin. The local treatment consists of massage and friction 
with bland oils or ointments. Galvanism sometimes improves the 
circulation and occasionally the X-rays may be of value. 

Fig. 124. Model in Neisser's Clinic in Breslau (Kroener). 

Fig. 125. Model in Lassar's Clinic in Berlin {Kasten). 

Fig. 126. Model in Freiburg Clinic (Johnsen). The universal form of 
scleroderma in a woman, aged forty-two years, who was suddenly at- 
tacked with swellings about the ankles 7 months previously. For 6 
months the skin of the whole body had been of boardlike hardness, 
shiny and deeply pigmented, with scattered lighter spots and excoria- 
tions here and there, especially about the anchylosed joints. The 
patient became intensely emaciated, and died of an acute pleurisy 
with effusion. 

Atrophia Cutis Idiopathica 

Plate 80, Fig. 127 

Under this designation are at present comprised several clinical 
conditions of wliich the most important are diffuse idiopathic cutane- 
ous atrophy, dermatitis atrophicans, and acrodermatitis chronica 
atrophicans {Herxheimer). In the two last named there is clear 
evidence of an antecedent inflammatory stage; but in regard to the 
so-caUed diffuse "idiopatluc" condition the evidence as to a prelim- 
inary inflammatory stage is conflicting. This point is of vital sig- 
nificance, for as a matter of fact the so-called "idiopathic" atrophy 
is often secondary; while conversely, if the lesion is really primary, 
it cannot be of the same nature as the secondary conditions, but 
should be classed with congenital and hereditary hypoplasia of the 

In even the most modern literature there appears to be a hopeless 
confusion between primary and secondary atrophy, and the impres- 
sion appears to prevail that the same picture may be produced 
whether the affection is dystrophic or secondary to an inflammatory 
stage. The more one looks into the subject the more the designation 
"idiopathic" seems to be unwarrantable. It can only imply that in 
a person born with sound integument, and in the absence of any 
exciting factors, atrophic conditions can develop. 

In order to comprehend such a condition we may invoke, for 
comparison, the disease scleroderma. Here we see many points of 
resemblance with our affection. There is usually a primary stage, 
which, however, may be latent. The localization is either diffuse or 
circumscribed ; in the latter case especially involving the extremities 
— in scleroderma the very fingers, but in the other form the hands 
and forearms or legs. Scleroderma, itself a most mysterious affection 
as far as its initial phases are concerned, causes, under typical condi- 
tions, a most thorough atrophy of the skin. 

Nevertheless, there is no close resemblance between the two con- 
ditions. In so-called idiopathic atrophy there is no retraction present, 
as in scleroderma. Instead of being hidebound, there is a laxness of 


Plate 80. 

Fig. 126. Scleroderma. 

Fig. 127. Atrophia cutis idiopathica. 

the skin, which is further suggestive of crumpled cigarette paper. 
But cases of scleroderma have been reported which fulfil all these 
conditions. Several authorities have recently expressed the opinion 
that all cases of dermatitis atrophicans represent abortive sclero- 

A survey of the sections on symptomatology, etiology and pathol- 
ogy of this affection in the more recent text-books throws but little 
light on our subject. The description applies equally to primary 
and secondary affections. 

In view of the anarchy which prevails in this field we can only 
sum up our existing knowledge by stating that we cannot be clear as 
to the primary or secondary nature of this disturbance ; that it affects 
the middle-aged and especially the old by preference ; that irrespec- 
tive of its origin it may progress and even involve the entire integu- 
ment; and that there is no known plan of treatment capable of 
modifying its course. 

Fig. 127. Model in Neisser's Clinic in Breslau (Kroener). 


Striae Distensae 

Plate 81, Fig. 128 

This is the condition originally described as "strise et maculae 
atrophicas. " Maculae occur so frequently, however, that in some local- 
ities the term is no longer employed. The lines have often been 
termed lineae albicantes from their shining quality. 

The phenomenon is normal in the gravida but is not of imiversal 
occurrence. The same is true of rapidly acquired adiposity of the 
abdomen and thighs. It is conmaonly held that the lesions appear 
after delivery or rapid loss of flesh, but since a rupture of the corium 
is believed to give rise to the striae, the latter might be in evidence 
before the loss of flesh. 

Observation shows that the lines are for the most part parallel, 
their length is several inches and width about a quarter of an inch. 
The color has been given as pure blue, livid or white, but these shades 
are largely fortuitous and of no diagnostic significance. It is safe 
to say that the lines are of a paler shade than the surrounding intact 

Fig. 128. Model in Freiburg Clinic (Voffelbacher). 


Plate 81. 







^^^^■yv-v^^^B ^^^^^^^^^^1 

b' * 1 


-■^ • J 

Br^L ^* 




^ t- .^ W—^^^^ 


Fig. 128. Striae distensae. 

Plate 82. 







Molluscum Contagiosum 

Plate 82, Fig. 129 

This mysterious contagious affection shows resemblances to 
numerous widely different dermatoses. It has been classed as a form 
of acne, sebaceous tumor and neoplasm ; and one of its oldest names 
(acne varioliformis) is based on its resemblance to the umbilicated 
vesicles of smallpox. For some years it was believed to be due to 
certain parasites — coccidia^ — but this view has almost been aban- 
doned. Under the microscope it represents a benign form of epi- 
thelioma, and presents some superficial clinical resemblance to 
multiple, benign cystic epithelioma. The lesions resemble cysts, in 
having fluid or solid contents, which may be squeezed out of a central 
opening. They leave no traces, not even in case of suppuration, 
which sometimes results. 

The lesions vary from pinhead to pea size, are multiple, and are 
either pearly white or pinli. They are discrete, but may form small 
groups, and while they may occur exceptionally in any area of integu- 
ment, are usually found on the face or genitals. They are firm to the 
touch, of globular outline, with slightly flattened summit, and natu- 
rally sessile, becoming pedunculated in some cases at a later period. 
Atypical varieties have been described. 


Not only can no parasitic cause be found for this affection, but 
even the conditions under which it can be propagated are barely 
known. Like impetigo contagiosa, it tends to prevail among the 
children of the poor and in institutions. There is a small per cent. 
of cases in which direct inoculation is evident, and it may also be 
inoculated experimentally. Despite its occurrence on the genitals, 
there is no evidence of venereal transmission. There is quite a con- 
sensus of opinion that it follows visits to bathing establishments. 
The affection was long believed to involve primarily the sebaceous 
glands, which if true would make the matter of contagion more 


intelligible. As a matter of fact, however, the disease begins in the 
rete and has no connection with glands or follicles. The central 
opening, which originally suggested the sebaceous gland theory, is 
part of the evolution of the tumor. 


The peculiar formations mth their central depressions and duct- 
like orifices, when typical, can hardly be mistaken for the lesions of 
any other affection. Atypical lesions about the eyes might be con- 
fused with milia or warts. Beginning lesions present some analogy 
to acne papules. 


Many cases terminate in spontaneous recovery in a few weeks or 
few months, but the contagious nature makes vigorous treatment 
necessary. Parasiticides, such as sulphur or mercurials in ointment 
form, rubbed in forcibly, are curative, and are usually prescribed if 
many lesions are present. The treatment for individual lesions is 
incision or expression, followed by cauterizing "with pure carbolic 

Fig. 129. Model in Lesser's Clinic in Berlin {Kolhow). 



Plate 82, Fig. 130 

This term is applied to a scar-like new-growth of the skin. Its 
resemblance to a scar is by no means accidental, for in the majority 
of cases it develops in a recent cicatrix, and in its mildest form is 
nothing but a redundant scar. In a degree one remove higher it 
appears at first las a redundant scar, but grows beyond the original 
scar limits; and in the highest degrees it appears to develop spon- 
taneously in sound skin. This, however, is very questionable, for 
in these so-called spontaneous or idiopathic cases the skin has almost 
always been subjected to friction and intermittent pressure ; and when 
we bear in mind that about half of these idiopathic cases occur over 
the sternum and have a history of mechanical irritation, the inference 
is that an initial abrasion or some other slight traumatism may have 
furnished the impulse for the new-growth. And we know, besides, 
that scar keloid so-called can follow a very small lesion of the skin. 
There is no doubt that a marked predisposition to these growths 
exists, but beyond the fact that negroes show a distinct tendency in 
this direction, we cannot formulate it. 

A keloid tumor, however produced, shows a marked tendency on 
the part of the fibroplastic tissue of which it is constituted to retract, 
like the ordinary scars of burns. As a result the growth has numer- 
ous processes resembling claws, whence the name. The superficial 
processes or roots of a keloid are roughly analogous to the so-called 
roots of a cancer of the breast which are also produced by the retrac- 
tion of the fibroplastic tissue; and keloids, like cancers, have a 
notable tendency to recurrence after removal, although they are not 


A keloid can hardly be mistaken for any other affection because 
its appearance must suggest a scar. 



This has always been far from satisfactory. Excision is always 
contraindicated. Palliative treatment (anodynes) is necessary at 
times when the growths are painful. A combination of fibrolysin 
injections, linear scarification and electrolysis may prove successful 
in some cases. Improvement often follows the use of the X-rays. 
Naturally the treatment is in part comprised under that of disfigur- 
ing, incapacitating and painful scars such as follow extensive 

Fig. 130. Model in Kaposi's Clinic in Vienna (Henning). 







Xanthoma Tuberosum Multiplex 

Plate 83. Figs. 131 and 132 

In this type of disease nodules occur, as the name implies ; but flat 
patches sometimes coexist. This form is only exceptionally seen about 
the eyelids, but occurs disseminated in various localities, so that it is 
termed xanthoma tuberosum multiplex. Favorite localities are the 
hands, knees, elbows, buttocks and feet. The individual nodes are 
about the size of a pea and as a riTle they are closely aggregated. A 
puzzling feature is the frequent association of jaundice, although the 
xanthomatous nodes and plaques in no wise owe their yellow color 
to bile. 

The coalescence of nodules may be so extreme that true tumors 
result. Otherwise the condition is simply very slowly progressive, 
with little or no tendency to disappear by involution nor to de- 


Zanthoma has been recognized as a- familial affection, cases having 
occurred in at least four generations. The lesions are known to de- 
velop in some of the internal organs. Little or nothing is knoTvn of 
the determining causes. The neoplastic tissues appear to contain a 
special kind of fat to which they owe their yellow color. 


Xanthoma tuberosum multiplex, when it occurs away from the eye- 
lids and vicinity, is hardly to be confused with any other malady. It 
is stated that urticaria pigmentosa has been known to simulate it. In 
theory it might be confounded with the so-called xanthoma of dia- 
betics. This, however, represents a fatty degeneration of disseminated 
inflammatory lesions. Occurring on or about the eyelids, it might of 
course be confused with xanthoma planum ; but xanthoma tuberosum, 
while it may occur on the lids in a flattened form, will always be 
accompanied by the tuberous lesions elsewhere on the body. 


As in the case of neoplasms of any sort, extirpation is the only 
treatment. The affection is weU adapted to curettage, and if the 
lesions are small or few in number, electrolysis or the use of moder- 
ately strong caustic solutions may be sufficient. If there is fear of 
disfiguring scars a strong salicylic acid plaster or coUodium solution 
applied repeatedly may cause the disappearance of the lesions. For 
large plaques on the elbows and knees the X-rays may be used. 

Fig. 131. Model in St. Louis Hospital in Paris, No. 655 (Baretta). 

Besnier's case. 

Fig. 132. Model in St. Louis Hospital in Paris (Baretta). 
Du Castel's case. 


Plate 84. 














Xanthoma Palpebrarum 

Plate 84, Fig. 133 

This affection seemingly has no connection with xanthoma tuber- 
osum multiplex. As the name implies, it is peculiar to the eyelids. 
It is roughly symmetrical and both the upper and lower lids may be 
affected. The lesions are of a chamois color and of oval form, from 
one-eighth to one-half of an inch in their long diameter. Adjacent 
lesions may coalesce and form irregular bands and patches. The 
affection is seen most frequently in women, particularly those show- 
ing dark pigmented rings around the eyes. Although rare in men 
it is occasionally encountered. 


But little can be said regarding the cause of the affection aside 
from the fact that it is known to possess a fairly definite hereditary 


This affection is frequently confused with typical xanthoma, espe- 
cially when the latter is seated in the lids, in which case it assumes 
a similar flattened type. The absence of lesions on the body, however, 
should prevent this diagnostic error. 


The growths may be destroyed by electrolysis, refrigeration, or 
by chemical caustics. Touching the lesions with pure nitric acid is a 
simple but effective treatment. 

Fig. 183. Model in Lesser's Clinic in Berlin (Kolbow). 


Atheroma Multiplex 

Plate 84, Fig. 134 

Wens, or sebaceous cysts, despite the above designation, are nsn- 
ally single and seldom niunerous. Since the contents of these cysts 
is ordinary sebaceous matter, the first impression is naturally that we 
have to deal with ordinary retention cysts from occlusion of the 
ducts. But not only are the latter often patent, so that the contents 
are easUy pressed out, but mere stoppage of a duct is evidently 
insufficient in itself to cause a wen. 

Wens may be of any size up to that of an orange, and after 
reaching a certain size — for example, that of a bean or an almond — ■ 
undergo no further change unless they inflame. Their favorite 
locality is the scalp and adjacent parts of the face and neck, and the 
back, but they may occur in any locality whatever. In certain locali- 
ties they show peculiarities which cause them to pass for special 
affections, as the chalazion of the eyelids, which are connected with 
the Meibomian follicles. They often occur in the scrotum, and some- 
times the labia majora are affected. In wens with patent duct, 
cutaneous horns are occasionally produced. 

Wens naturally lie beneath the skin, which moves freely over 
them ; and if they do not inflame the contents gradually harden. It is 
asserted that if there is no patent outlet the growths become more 
bulging. A low grade of inflammation causes the cyst-wall to adhere 
to the skin, which itself may inflame, become thin and ulcerate. An 
ulcerated wen may show papillomatous outgrowths, and may even 
become the seat of an epithelioma. 


Without a history of the case, a wen might readily suggest a sub- 
cutaneous granuloma, either s)T)hilitic or tuberculous, especially if 
no opening is to be seen. The presence of the latter, and the escape 
of sebaceous matter therefrom under pressure, is characteristic of 


•wens. In dubious eases a needle puncture might be made, but the 
indications for extirpation are so marked that refinements of diag- 
nosis are hardly called for. 


This consists in incising the skin and shelling out the cyst, save in 
small, beginning wens, which may be simply punctured, evacuated 
and cauterized. When adherent to the skin, careful dissection is 

Fig. 184. Model in Neisser's Clinic in Breslau (Kroener). 


Lupus Erythematosus 

Plate 85, Figs. 135 and 136; Plate 86, Figs. 137 and 138; 
Plate 87, Fig. 139 

This affection comprises two types of disease, which differ so 
notably as ahnost to constitute clinically separate affections. Never- 
theless, they show transitions and the ability to pass from one phase 
into the other. 

The first type to be described has a decidedly rashlike character, 
and is kno^-n as the exanthematous or disseminated. It varies greatly 
in degree and severity, and in its mild forms seems to be regarded by 
most authors as belonging to the localized, circumscribed type. In 
this form a few scattered lesions may appear on the face, and perhaps 
also on the hands and arms. These lesions are mere erythematous 
spots, varying much in size, but seldom larger than a bean. They 
may be very few in number, with a tendency to appear on or about 
the nose, in which locality they may simulate seborrhoic dermatitis or 
acne rosacea. On the other hand, the face, hands and forearms may 
be quite tliickly sprinkled with lesions, so that they bear considerable 
resemblance to erythema multiforme. It is difficult to associate such 
insignificant-looking lesions with the word lupus. Like any other 
exanthem, these spots may disappear spontaneously, and often yield 
readily to local treatment. As a rule, however, they tend to reappear. 
Wlien they vanish they may leave behind superficial temporary white 
scars. Some spots appear to sear in the centre only. Subsequent 
lesions, when they appear, no longer show any tendency to recovery 
and become ordinary circumscribed chronic lesions which make up 
most of the cases of this affection. 

There is also an infrequent, much more severe and generalized 
form of exanthematous lupus which may involve a much greater area, 
and be attended with constitutional SAonptoms. This type is often 
fatal. Most of the cases are associated with general tuberculosis, 
others with nephritis or syphilis. This type has been known to 
develop in subjects already affected with the ordinary chronic 
localized form. The eruption may itch notably, and show much poly- 


Plate 85. 

















^^^^^^^^^^k / 



^^^H^' ' 







Plate 86. 







morphism. It frequently resembles a generalized erythema multi- 
forme, to such a degree, in fact, that no distinction can at first be 

However interesting and striking these cases may be, lupus erythe- 
matosus is for all practical purposes a very different affection — an 
eminently chronic, localized process, confined to certain areas. These 
comprise the nose and adjacent parts of the cheeks, the ears and 
region behind them, the scalp, fingers and hands, and occasionally the 
toes. The same subject does not as a rule present lesions on both the 
head and extremities, so that clinically two different local types may 
be represented. Exceptionally other localities near the favorite ones 
may be involved, as the eyelids and the red border of the lips. The 
most striking and characteristic location is the so-called butterfly 
area, in which one large patch occupies the nose and entire infra- 
orbital regions ; and generally speaking, symmetry is highly typical 
of this form of disease. Thus, if one ear is affected the other will 
be. If there is a patch behind one ear, there will be a corresponding 
one on the opposite side. If a large number of cases are analyzed, it 
will be found that the majority follow a single local type, the lesions 
being confined entirely to the nose, cheeks and lobules of the ears. 

These lesions may be perfectly flat or even slightly below the 
level of the skin, but as a rule more or less infiltration is present, so 
that they are elevated above the skin. These variations are due to 
the fact that in chronic erythematous lupus there is always a new 
formation of small cells which have some tendency to undergo atro- 
phy. We may therefore see either hyperplastic or atrophic change 
and sometimes both side by side. This infiltration is able to destroy 
the integrity of the skin and produce scarlike tissue without previous 
ulceration. The resulting lesion is not a true scar and there is little 
or no retraction, but it imposes itself as scar tissue. The infiltrated 
skin has a bright red color, and does not pale on pressure ; this is true 
also of exanthematous lupus. Thick, closely adherent scales may be 
present on the patches, and the borders are sharply outlined. Excep- 
tionally, even after considerable infiltration, the skin may remain 
intact, so that after the retrograde changes it appears normal. On 
the fingers or elsewhere in the chilblain area the lesions may be 
livid instead of red. Exceptionally, a patch may appear edematous. 
Patches in the hairy scalp cause localized permanent alopecia. 


But little is knowm of the intimate nature of the malady. It has 
often been claimed that the disease is in some manner dependent upon 


tuberculosis, but proof of this fails. Bacilli do not appear in the 
lesions, and to claim that circulating toxins are responsible leads to 
nothing. Its choice of locality may be determined by the fact that 
these areas are naturally hyperemic or congested, and it sometimes 
seems to develop in previous affections in these localities. 


Beginning lupus about the nose often suggests seborrhoic derma- 
titis or rosacea, and as the disease may begin in these forms, it may 
be impossible to give a positive opinion for a time. In lupus the 
sebaceous follicles are often very prominent. The patches of exan- 
thematous lupus may simulate eczema, as they may itch and show 
small papules and vesicles. The one disease which offers the closest 
resemblance is lupus vulgaris, and in a small percentage of cases 
diagnosis becomes so difficult that a hybrid form has been spoken 
of. Otherwise, the resemblance is chiefly illusional, for in the great 
majority of cases the affections present little in common. 


In a case with some tendency to spontaneous improvement, vigor- 
ous treatment may bring about complete recovery; but in the great 
majority of cases it is a question of improvement only. 


Internal treatment should be directed first of all to the correction 
of any defect which may be found in the patient 's general health. 

A great many remedies have been recommended on account of 
their supposedly specific action upon the disease itself or upon the 
toxemia causing it or for their power of contracting the dilated blood- 
vessels. The most important of these are arsenic, the salicylates, 
carbonate of ammonia, quinia, the iodides and ichthyol. The results 
from all, however, are usually disappointing. 

In the hyperemic-spreading cases iodine in the form of iodoform 
is frequently of value. The spreading is checked, the acute in- 
flammatory condition subsides and occasionally a cure is effected. 
Whitelwuse recommends that it be given in one-grain pills, coated 
with keratin or salol to prevent solution in the stomach. The dose 
is one pill three times a day after meals, gradually increased to the 
limit of tolerance, which is usually eight or nine pills a day. Its 
effect upon the digestive tract and upon the kidneys must be care- 
fully watched, and its use should be continued for several months. 
Bulkley recommends phosphorus in the form of Thompson's solution 
in increasing doses pushed to tolerance. 


For external use the number of remedies is even larger than for 
internal, and in most cases their action is quite as disappointing. 
The choice of the remedies will depend upon the type of the disease 
and the character of the individual skin. 

In the acute inflammatory or vascular type only soothing applica- 
tions are indicated, such as a calamine and zinc or a zinc and 
magnesia lotion and boric acid or mild ichthyol ointments. 

As the acute process subsides, more active remedies can be used, 
such as painting the surface with liquor potassse, allowing it to dry, 
and then covering it with collodion. The collodion peels off after 
four or five days and the process is repeated. 

Lotio alba gradually increased in strength from 3i each of zinc 
sulphate and potassium sulphuret in §iv of water to 3vi of each, is 
often valuable in this stage. It is to be applied from two to four 
times a day. 

Resorcin, from five to fifty per cent, in alcohol, is also useful. 

Green soap applied either as a plaster or in the form of the 
tincture removes the scales and may stimulate a healing process. 

The best results from all of the above are seen in the semiacute 
eases which show only slight infiltration : in the fixed chronic cases 
they are of but little use, and more radical methods must be employed. 
The action of all active remedies must be watched closely, and when- 
ever an inflammation is excited they must be discontinued and one of 
the soothing applications used until this subsides. 

In the chronic fixed cases one of the best remedies is equal parts 
of tincture of iodine and glacial acetic acid applied two to four times 
a day. The amount of iodine can be increased as the skin becomes 

Hollander recommends that quinine in increasing doses be used 
in conjunction with iodine externally. 

Curettage is beneficial, especially ia those cases with excessive 
scaling and thickening. 

The remedy, however, which offers the best results is carbon 
dioxide snow. Its use should be restricted to those cases where the 
process has become stationary; or to lesions which have persisted 
for several months and show no tendency to spread. 

There are several ingenious mechanical devices for making the 
CO2 crayon, and while they are convenient, a piece of blotting-paper 
will answer the purpose quite as well. The blotting-paper is rolled 
to form a cylinder about three or four inches long with a diameter 
to fit snugly over the outlet of the tank containing the liquid COj. 


This is firmly bandaged on the outlet, the tank inverted and the valve 
opened gradually allowing the liquid CO2 to run out. With a little 
practice a firm, hard crayon is obtained, which can be trimmed with a 
knife to the desired size. 

The reaction f oUowiug the use of the snow is often quite severe, 
and it is not advisable to use it over a surface larger than one or 
one and a half square inches at one treatment. Over the bony prom- 
inences, and where there is little subcutaneous tissue, as the nose, it 
must be used very carefully to avoid too much destruction of tissue 
and sloughing. It should not be used at all on the ears. It should be 
applied first at the edges of the patch to be treated, and at least one- 
eighth of an inch of normal skin should be Included in the process. 
The amount of pressure and the duration of its application vary in 
individual eases, and in the beginning it is advisable to limit both. 
Twenty seconds, with moderately firm pressure, is safe, and from this 
one can estimate what will be necessary later. The crust which 
forms usually separates in from ten to fifteen days. 

Figs. 135, 136 and 138. Models in Neisser's Clinic in Breslau (Kroener). 

Fig. 137. Model in St. Louis Hospital in Paris, No. 1437 (Baretta). Vi- 
dal's case. — Symmetrical lupus erythematosus of the hands of 2 years' 
standing. The face was likewise affected. 

Fig. 139. Model in Freiburg Clinic (Johnsen). The superficial invasion of 
the skin of the cheeks permits the recognition of the existence of 
numerous small circular lesions, especially in the marginal portions of 
the disease. Under internal treatment with quinine and painting with 
iodine the affection was soon reduced to minimal proportions. 


Plate 87. 










Lupus Pernio 

Sjnonym: Chilblain lupus 

Plate 87, Fig. 140 

It has already been stated that lupus erythematosus may appear 
only upon the hands, and that when confined to the fingers and toes 
it may occupy the chilblain area and possess a resemblance to chil- 
blains otherwise. Most authors make a special type of disease of 
chilblain lupus, asserting it to be a different affection from lupus 
erythematosus. They point to the fact that similar congested, livid 
areas appear in other chilblain localities, as the nose and ears ; that 
the subjects are anemic with poor circulations, and are subject to 
chilblains, and that the affection itself may begin upon this founda- 
tion. In this form of lupus the thick adherent scales, the dilated and 
obstructed sebaceous ducts, and the sharply outlined, elevated border 
are absent. The affection may recover without scar-formation, even 
after years of persistence. The same secondary lesions develop as in 
severe cases of common chilblains. The only distinction between the 
two is the principal fact that chilblain lupus is present the year 
around, once it has begun. But if the face and ears are involved 
together, as is often the case, the condition could not, of course, be 
mistaken for the effects of the weather, even in winter. 


The management is essentially that of severe chilblains, viz., 
attempts to improve the circulation by internal and local treatment. 
Severe local measures are contraindicated. 

Fig. 140. Model in St. Louis Hospital in Paris, No. 16D4 (Baretta). 

Terineson's case. 


Lupus Vulgaris 

Plates 88 to 94, Figs. 141 to 152 

This form of tuberculosis of the skin is believed to differ from 
other species in being caused by the action of a limited number of 
germs of low virulence upon tissues which may have a certain predis- 
position or immunity. They resemble the so-called tertiary lesions 
of tuberculous infection, and also bear a close resemblance to the 
tertiary syphilitic lesions of the corixmi. On the other hand, it is 
believed that they originate from inoculation in or near the seat of 
the lesions, and that the low degree of virulence may come about from 
the fact that the subject has become partly immunized by the dis- 
ease. Transitions occur between lupus vulgaris and ordinary inocu- 
lation tuberculosis (where a predisposition is not in question), and 
typical lupus itself plainly results from inoculation in certain cases. 
A special disposition to the disease is furnished by certain localities, 
as portions of the face and hands; these agree roughly with the 
areas of choice in circumscribed erjrthematous lupus, and to this 
parallel is due the fact that the latter affection, although not techni- 
cally destructive enough to merit a designation like lupus, has come 
do^\Ti to us as a process cognate with true lupus. 

The affection begins as a characteristic nodule occupying the 
thickness of the true skin. These are minute and readUy coalesce to 
form disease foci. When one of the latter has become conspicuous 
it is seen to have a peculiar hue, often likened to those of apple-sauce 
or apple-jelly. It becomes less marked on pressure, but still has a 
yellowish-bro'wn color. This corresponds to an infiltration of 
granulomatous tissue, Avhich soon softens, so that a fine probe readily 
enters it. This new tissue has already destroyed the thickness of the 
skin, yet the lesions may long remain at an apparent standstill before 
any further changes occur. New lesions tend to appear close by, 
however, so that in time a patch of considerable size has been formed. 














Plate 89. 















These patches are usually a dull or bright red. In time the older 
lesions begin to show regressive changes. The natural tendency is 
to very slow absorption, leading to atrophy of the derma. During 
this process a peculiar anomaly of desquamation is usually present. 
Large masses of scales become partly loosened, but remain adherent, 
so that when forcibly detached hemorrhage results. At the comple- 
tion of the atrophy this scaling ceases. The other termination is by 
ulceration, and this may be due largely to mixed infection from 
without. The ulcers discharge pus, which quickly dries into dark- 
colored crusts. In certain cases exuberant granulations form. An 
old patch of lupus which has slowly formed during years presents a 
characteristic appearance ; several or all of the changes just described 
may be present at the same time. The new lesions naturally appear 
on the margin of the patch, sometimes forming a serpiginous border 
so characteristic of parasitic disease in general. 

Despite the areas of preference, the disease readily occurs on the 
limbs, buttocks, and in fact in almost any locality, and it is not 
uncommon to see it develop simultaneously in widely separated 
localities. It attacks any of the superficial mucosae, and may be 
primary here as well as secondary. The great disfigurement which 
it is capable of causing is not due to any penetrating power or ability, 
like cancer, to attack all structures, but to cicatricial or atrophic 
retraction about delicate orifices, and to interference with the nutri- 
tion of the more fragile bones and cartilages. Hence the sinking in 
of the nose. On the other hand, ordinary acute tuberculosis caused 
by large numbers of virulent bacilli is able to attack any of the 
tissues and produce destruction in a short interval. The area 
involved, however, is fortunately small, so that clinically there is no 
resemblance to lupus. There is, however, a process described by some 
authors as acute lupus, in which there are evidences of active inflam- 
mation and a tendency to rapid disintegration. 

The affection, in the majority of cases, begins in childhood, and 
since it is quite compatible with a fair state of nutrition and does not 
kill either directly or indirectly, and, moreover, since it tends to 
progress or at least to remain stationary and is not especially 
amenable to treatment, the patient is almost sure to suffer with it 
during the entire life, be this long or short. Since practically its 
progress is very slow, the phenomena vary essentially with the 
duration. The older the case the greater the amount of atrophic and 
cicatricial tissue. The intensity of the disease at a given period is 
shown by the extent of new patches of disease. A time may come 


when there are no longer any fresh nodules, the lesions then being 
wholly made up of the secondary changes. Although the disease may 
be extinct, or at least latent, the slow retraction may still be in evi- 
dence. Thus the entire face may be transformed to atrophic and 
cicatrized skin, and the apertures of the nostrils, eyelids, and even the 
mouth may be narrowed to an extreme degree, the nasal prominence 
being at the same time affected. Yet with all this local mischief the 
general health may remain excellent. The fingers and toes may also 
undergo analogous changes. 

Typical lupus is but slightly raised above the skin level during 
the period of infiltration, and the exuberant granulations which may 
form on ulcerated surfaces have been mentioned. But aside from this 
there is a distinct tendency in certain individuals to proliferation of 
the various tissues which make up the corium. There results, then, 
clinically, such varieties as lupus hj^jertrophicus, lupus papilloma- 
tosus, and lupus verrucosus. The same occasional tendencies are seen 
in other destructive diseases of the skin, and are doubtless due to 
individual peculiarities, although lupus verrucosus occurring on the 
fingers or hands is seen in butchers and dissectors ■without special 
predisposition, and seems to stand midway between true lupus and 
actual inoculation tuberculosis. The typical lupus nodule does not 
occur here, which has led to the rejection by many of this affection 
as a form of true lupus. 

Lupus is also atypical in the lesions known as scrofuloderma, 
which often stand in actual relationship to scrofulous glands and 
acute scrofula in various organs. Some of these lesions represent 
small cold abscesses of the corium, and in general there is here a 
transition between true lupus and the more acute forms of tuber- 


Much has been said under this head, and it only remains to discuss 
the probable relationship between true lupus and general or pul- 
monary tuberculosis. The evidence points to the fact that in lupus, 
as in certain so-called scrofulous affections, the patient seems to have 
become partly immunized to fatal tuberculosis. Nevertheless, in a 
certain per cent, of cases there is no immunity, and the patients perish 
of pulmonary tuberculosis. There is no doubt whatever that lupus 
patients come of tuberculous stock in a preponderating proportion. 


Plate 90. 







Plate 91. 

Fig. 147. Lupus vulgaris serpiginosus. 

Plate 92. 

Fig. 148. Lupus vulgaris (elephantiasis 

Fig. 149. Lupus vulgaris (mutilatio). 

Plate 93. 












Typical lupus may easily be recognized from the chp^racters al- 
ready given. Atypical forms may so mimic other destructive affec- 
tions, such as lupus erythematosus, tertiary syphilis, rodent ulcer, 
epithelioma, tubercular leprosy, blastomycosis, etc., that diagnosis 
for the time may be quite impossible, or at least extremely difficult. 
The von Pirquet test and the Wassermann reaction are often of great 
help in differentiating lupus from syphilis. Certain fungi (blasto- 
myces, etc.) may produce lesions accurately simulating lupus of the 
face and extremities. This confusion is more likely to occur in tropi- 
cal countries. The only way to solve these puzzles is by microscopic 
studies, which may reveal the presence of blastomyces. Leprosy, 
when it first invades the nasal chambers and septum, readily simu- 
lates lupus, or, perhaps better, tuberculosis. The reason for the 
reciprocal simulation of granulomatous affections is due to the fact 
that these represent a group disease, and behave more or less alike. 
A rodent ulcer which heals partly while still progressing resembles a 
small isolated patch of lupus at times, and it is now known that 
lupus can begin in the elderly. Again, epithelioma readily develops 
in an ulcerated lupus, and in such a case has to be differentiated from 
lupus with overgrowth of tissue. An ulcerated lupus may also pass 
directly into cancerous ulcer without any additional infiltration. 


The Finsen light treatment is in some respects a specific for 
lupus, the X-rays, however, constitute a more available resource, 
having nearly as great efficacy. The large number of exposures 
necessary and the resulting tediousness, however, make some more 
rapid method in demand for all save those who wdsh above all for 
cosmetic results. One plan of treatment which may be summed up 
as asepsis and antisepsis seeks to minimize the disease by excluding 
septic infection. This may be carried out in a variety of ways. The 
lupus nodules will then pursue an uncomplicated course. The anti- 
septics most in use are pyrogallic and salicylic acids. This treatment 
can, of course, be pursued with lupus of any stage or variety; and 
it seems to be preferred by many over active destructive measures. 
Destructive cautery, curettage, and excision seem to be indicated less 
and less since a combination of X-rays with antiseptics have come 
into vogue. The latter does far more, perhaps, than merely prevent 
secondary infection. Pyrogallic acid has considerable power as a 
mild destructive caustic. If the superficial tissues are first softened 


by salicylic acid, pyrogallic acid is able to penetrate into the tissues 
and perhaps to destroy the tubercle bacillus and arrest the small cell 
infiltration. It thus works hand in hand with the bactericidal action 
of the rays. 

Figs. 141, 142 and 150. Models in Freiburg Clinic {Johmen). 

Figs. 143 and 147. Models in Neisser's Clinic in Breslau {Kroener), 

Fig. 144. Model in St. Louis Hospital in Paris, No. 1059 (Baretta). 

Guibout's case. 

Fig. 145. Model in St. Louis Hospital in Paris (Baretta). Besnier's case. 
Male, aged fifty-one; disease of 22 years' standing, only slightly 
treated, especially never with thermo-cautery. 

Fig. 146. Model in Neisser's Clinic in Breslau {Kroener). Patient is 

still living. 

Figs. 148, 149 and 151. Models in Neisser's Clinic in Breslau {Kroener). 
Fig. 152. Model in Freiburg Clinic (Johruen). 


Plate 94. 

Fig. 152. Lupus vulgaris mucosae oris. 

Fig. 153. Verruca necrogenica. 

Verruca Necrogenica 

Synonym: Post-mortem wart 
Plate 94, Fig. 153 

Under lupus vulgaris mention was made of a form, lupus verru- 
cosus, described by authors, which in some instances appeared to 
result from direct inoculation with tuberculous matter. Such lesions, 
while sharing some of the features of conunon lupus, are usually 
held to be more allied to ordinary inoculation tuberculosis, about to 
be described. In these cases there is no predisposition required. 
Butchers and dissectors alike may be professionally inoculated, the 
accident occurring as a rule over a knuckle. The lesions must not 
be confounded with dissection pustules which are due to ordinary 
pyogenic cocci. The lesion develops slowly, resembling a wart in its 
evolution. There is an overgrowth of papillsc, a slight secretion of 
pus and the formation of a crust, which forms again whenever de- 
tached. A considerable size may be attained — an inch in diameter; 
and as the lesion increases there is some disposition to heal in the 
centre. That such a condition may pass by transitions into lupus 
verrucosus is manifest. Since no predisposition or special immunity 
exists, the natural defensive forces are operative and the lesion either 
heals of itself in time or in rare cases infects the organism with 
acute general tuberculosis. Fatal cases are very rare, however, and 
the more severe cases are probably due to mixed infection, \\ith 
lymphangitis and general toxemia. 

A condition known as tuberculosis verrucosa cutis, which occurs 
on the hands and feet and may be very extensive, occupying an entire 
foot, stands in some common relationship ynth. lupus verrucosus and 
verruca necrogenica. 


Post-mortem wart must be differentiated from ordinary warts, 


which often grow rapidly after local irritation, and post-mortem 
pustules. A microscopic examination should decide the matter. 


It should be easy to destroy these growths with the thermocautery. 
Cases may arise in which it would be more expedient to use the 

Fig. 153. Model in Freiburg Clinic (Jacobi), 

Plate 95. 








Tuberculosis Linguae 

Plate 95, Fig. 154 

The tuberculous ulcer, or as it is more commonly called rhagade 
of the tongue because of the greater frequency and importance of the 
fissured form, is in the great majority of cases situated on the sides 
or dorsum of the organ. The first stage is the deposition of tubercles 
which sooner or later break down. The ulcer, when one forms, seldom 
exceeds the size of a bean. It is of variable depth and presents a 
grayish-green floor. Sometimes there is an attempt to granulate, 
notably after treatment. The edge is usually undermined and some- 
what indurated. The rhagade is more common and is narrow and 
deep in comparison with the ulcer. It may appear shallow until the 
edges are separated, may even appear as a mere furrow. It may 
persist for a long time and eventually take on more of an ulcer 
form. Meanwhile new tubercles may form and ulcerate. The slow 
course sometimes pursued suggests an analogy with lupus. Tuber- 
culous lesions of the tongue are usually secondary, but exceptionally 
they seem to be primary and as such have a relatively good prognosis. 


This is often made with great difficulty. Syphilis and cancer are 
the principal diseases to be excluded. 


This in primary tuberculous ulcer should be radical. In the 
milder cases, if the diagnosis is assured, a wedge-shaped section 
should be removed. If the area involved is considerable the paquelin 
or galvano-cautery, the curette, lactic acid, iodoform, and creosote 
shoTild be our chief resources. 

Fig. 164. Model in St. Louis Hospital in Paris, No. 1768 (Baretta). 

Tenneson's case 


Tuberculosis Nasi 

Plate 95, Fig. 155 

Two lesions aside from lupus may occur about the nostrUs from 
tuberculosis. One is the tuberculous tumor, or gunama, which may 
be primary, and forms just within the nostrils, usually in the septum. 
This may soften and ulcerate. The other lesion formed by the 
coalescence of miliary tubercles to form a typical tuberculous ulcer 
is seen as a rule only in people with advanced phthisis and is ex- 
tremely rare. There is reason to believe, however, that it may occur 
in latent pulmonary tuberculosis. The lesion resembles in every way 
the types seen in other localities. 

Fig. 155. Model in St. Louis Hospital in Paris, No. 2236 (Baretta). 

Hallopeau's case. 


Plate 96. 

















Lichen Scrofulosorum 

Plate 96, Fig. 156 

This affection is not conspicuous and gives rise to but little discom- 
fort. The primary lesion is a miliary papule, these being closely 
grouped. They are red only at the outset. Sooner or later they 
become decolorized and may be either yellowish or skin-colored, in 
the latter case resembling goose-flesh. Sometimes they are tawny or 
brownish, as if from pigmentation. The closely set papules are each 
surmounted by a little scaliness and when involution begins the more 
centrally seated papules go first, and cireinate lesions are often 
formed. Sometimes minute hemorrhages occur giving the lesions a 
livid hue. In certain cases the follicles seem to be implicated more 
directly and the papules then contain a sebaceous plug. 

The patients are usually accidentally found to have this peculiar 
eruption on the trunk, usually about midway. The subjects are chil- 
dren or young adults of scrofulous habit. Of this affection it may 
be said that aside from the lesions themselves there are no symptoms. 
In rare cases similar lesions are seen on the limbs. 


The affection is believed to be a tuberculide, and in a few cases 
bacilli have actually been found. It stops short of being an active 
tuberculosis, although histologically it seems to consist of a tuber- 
cidous process about the hair-follicles. From the results of experi- 
ments it is possible that the process is due to the action of the toxins 
alone, although the rationale is obscure. It is known that scrofulous 
lesions of whatever kind are much less virulent than tuberculous ones, 
and that the subjects appear to have become immunized in a measure. 


There are a number of affections which produce miliary papules, 
but the seat, grouping, color and collateral evidences of scrofula 
should make the diagnosis. Other affections are keratosis pilaris, 


papular eczema, lichen urticatus and syphilis, and in none of these, 
save perhaps when the limbs are involved, should there be any 
possibility of confusion. 

Prognosis and Treatment 

With no tendency to absolute recovery, since new lesions may 
replace old ones, the affection is nevertheless readily controlled by 
antiscrofulous measures — chiefly cod-liver oil internally and exter- 

Fig. 156. Model in Freiburg Clinic (Johnsen), 

Erythema Induratum Scrofulosorum 

Synonym: Bazin's disease 

Plate 96, Fig. 157 

This affection bears considerable resemblance to erythema nodo- 
sum, being seated like the latter chiefly in the legs; it is, however, 
always a chronic condition, as a result of the continual appearance 
of new lesions. The lesions may be palpated beneath the skin before 
they become visible. They are then no larger than peas, and increase 
very slowly in size, nearly that of an English walnut. The skin over 
them becomes livid. They may in time undergo spontaneous involu- 
tion or soften and ulcerate. Under the latter condition they naturally 
resemble syphilitic gummata. There is no suppuration, and the 
process is really a central necrosis, the resulting loss of substance 
being small at first. Eventually the entire nodule sloughs and this 
may even occur at the outset. There are several other clinical forms, 
as for example when a large node undergoes necrosis at two points, 
or two closely placed nodules each ulcerate. 

The patients are almost always girls and women in poor health 
and circumstances and the lesions are largely peculiar to the legs, 
especially the lower portion. In a case of some duration various 
sized nodules and ulcers are seated side by side and between the 
lesions the skin appears purplish. Scars may be present and small 
nodules may be felt under the skin. 


This affection is believed to be related to tuberculosis, but the 
connection is hard to trace as the bacilli have never been found. The 
presumption is based on histologic and inoculation tests ; also on the 
scrofulous habit of the patients. 


The resemblance to multiple syphilitic gummata is at times start- 
ling, but the course is more indolent, and late syphilis is not a 


symmetrical disease. Erythema nodosum is at the begimiing an 
acute disease while the other is sluggish; the former, while it may 
become chronic, never ulcerates, while the latter as a rule does. The 
bright yellow discharge from the lesions is said to be characteristic. 


Tlie scrofulous habit must be antagonized and if this can be done 
the prognosis is good. 

The usual regimen is prescribed. The best remedy is rest. The 
ulcers heal up under mild antiseptics and ointments which encourage 

Fig. 157. Model in Freiburg Clinic (Vogelbacher). 


Plate 97. 

Fig. 158. Scrophuloderma. 

Fig. 159. Papulonecrotic tuberculide. 




Plate 97, Fig. 158 

This term has been and is still rather loosely applied. It should 
be a generic term for all the cutaneous lesions which are clinically 
allied to scrofula in general. From this viewpoint affections like 
erythema induratum, and lichen scrofulosorum should be the leading 
representatives. From a narrow viewpoint the term is only applied 
to the cutaneous lesions which follow the rupture of a scrofulous 
abscess due to suppurating lymph nodes. Scrofuloderma is supposed 
to be different both from true tuberculosis of the skin and from the 
tuberculides so-called. The term is here applied to lymphoid swell- 
ings whether of original subcutaneous lymph nodes or independent 
formations in or under the skin. When these formations undergo 
caseation and indolent suppuration results, the overlying skin be- 
comes thinned and livid and eventually gives way. There remain cer- 
tain ulcers or shallow sinuses, the latter often multiple. The skin 
about them has a peculiar purplish color, the ulcers are undermined, 
granulate imperfectly, and have but a scanty secretion. Sometimes a 
fragile cicatrix forms. In these cases we may see supervene the so- 
called inoculation lupus or even an active tuberculosis, showing the 
close relationship of all these processes. 

In certain patients who seem, while fairly healthy, to have been 
ravaged by the most polymorphous type of scrofula, so that hardly 
any tissue seems to have escaped, a peculiar eruption of papulo- 
pustules occurs, resembling most closely a syphUide of the same 
character. Before the introduction of the term tuberculide, this 
affection was termed by Duhring and Bulkley scrofuloderma. By 
exclusion it could be showm to be none of the kno-wn affections 
and the eminently scrofulous character of the subjects, who seem 
never to have had any other illness than some form of scrofula, causes 
the diagnosis of scrofuloderma. The affection consists of small 
papulopustules, of a torpid character, livid or brownish, scattered 
sparsely over the face, trunk and limbs. The lesions leave scars. 



The ulcerative lesions often resemble syphilis, but this disease 
should be readily excluded by the absence of other symptoms. 


The general health of the patient should be improved. Cod-liver 
oil, iron, arsenic, hypophosphates, etc., are indicated. Locally the 
lesions should be treated on general surgical lines. 

Fig. 158, Model in Neisser's Clinic in Breslau (Kroengr). 


Papulo-Necrotic Tuberculide 

Synonyms : Folliclis, Necrotic granuloma 
Plate 97, Fig. 159 

The papulo-necrotic tuberculides belong to a large group of skin 
manifestations, showing a great variety in appearance, but possessing 
many similar characteristics. They are frequently associated with 
tubercular manifestations elsewhere, such as tuberculous disease of 
the lymph-glands or lungs. The essential, and most frequently seen 
lesions are small, indurated, extremely indolent granulomas, showing 
a tendency to undergo central softening and necrosis. The site of 
each resolved lesion is marked by a prominent depressed, punched- 
out scar, much like that of variola. The lesions are bilateral and 
rather symmetrical. They appear most frequently on the upper 
extremities, particularly the forearms and hands. They occur mostly 
in individuals of scrofulous habit or history, and are frequently 
met with in chlorotic factory girls, with a depressed peripheral 

The relationship between the tuberculides and tuberculosis is a 
very close one, but the exact nature of this relationship is unknown. 
Histologically, giant cells and a tuberculous architecture have fre- 
quently been demonstrated, but the tubercle bacillus has not been 
found. Many cases show only changes incident to simple inflam- 


The symmetrically distributed indolent papules, with necrotic 
centres, and variola-like scars, together with the history and course 
of the disease, will serve to differentiate it from syphilis. 


The disease is extremely chronic, and may continue for years. 


As the disease occurs mostly in those in poor general health, 
fresh air, sunshine, and good food are of prime importance. The 


internal remedies vary wath the indications of each individual case. | 

Cod-liver oil and iron are frequently used, and are often of decided ^ 

value. Tuberculin therapy has apparently cured, or greatly improved, j 

a number of cases. Ammoniated mercury ointment, in from five to * 

ten per cent, strength, has proved the most valuable local application. > 
Antiseptic washes of mercuric chlorid (1:5000) or boric acid have 

been used. Curetting, with the subsequent application of pyrogaUol '[ 

salve has been recommended. Where the lesions are few excision may \ 

be practised. Good results in some cases have followed the applica •■ ' 
tion of the Finsen-light treatment. The X-rays are of less value. 

Fig. 159. Model in Neisser's Clinic in Breslau (Kroener). 


Plate 98, 

Fig. 160. Ulcus endemicum (ropicum. 

Ulcus Endemicum Tropicum 

Plate 98, Fig. 160 

Under this designation we find comprised a number of conditions 
old and new: the Biskra button, Aleppo evil, oriental boil, etc., and. in 
recent years "Leishraaniosis ulcerosa, cutic," due to the fact of its 
trypanosome origin. 

From the earliest records, we have known that various local condi- 
tions, which closely resemble one another, impose themselves upon us 
as separate affections, having separate local designations. These 
affections may be traced from Morocco to the Ganges. Briefly 
summed up we have to do with chronic ulcers, sometimes multiple, on 
exposed localities. Some sort of insect undoubtedly acts in propa- 
gating this affection, not only from one subject to another, but in the 
same individual. The lesion, at first an itching papule, becomes in 
time a broad, itching pustule, covered with a crust. Kemoval of the 
latter shows a deep ulcer of uneven surface and various shades of 
color. Smaller pustules appear at the periphery, break do■\^^l and 
become continuous with the mother pustule, increasing its area so 
that it may attain a diameter of several inches. The latter may 
slowly heal, perhaps only after years. 


This lies in recognizing the extreme chronic occurrence of a sore 
on an exposed surface. 


Although extremely chronic the ulcers sometimes heal sponta- 


Destruction of an entire structure. 

Fig. 160. Model in St. Louis Hospital in Paris (Baretta). By permission 
of Dr. Beurmann, from Iconographia dermatologica, No. TV. 



Synonyms: Leprosy, Elephantiasis Griecorum, Leontiasis, Satyriasis, 


Plate 99, Figs. 161, 162; Plate 100, Figs. 163, 164; Plate 101, 
Fig. 165; Plate 102, Fig. 166 

This is one of the oldest endemic affections, and from its disfigur- 
ing effects is readily recognized as the elephantiasis leontiasis and 
satyriasis of the Greeks. The connection between this disease and 
the. satyrs of mji;hology is obscure ; it may have referred to the fact 
that lepers were forced to shelter themselves in the depths of the 
woods, and this with their deformed appearance possibly suggested 
the opprobrious appellation. The usual explanation that lepers suf- 
fered with inordinate venereal desires, therein resembling satyrs, is 
not in accordance with facts, the contrary being the ease. This, 
however, may have been the popular belief. The- word lepra meant 
to the .Greeks only a scaly affection, probably psoriasis. The word 
lepra was. first applied to leprosy by the Arabians, who confined the 
term elephantiasis to a different disease (filariasis). Much ingenuity 
has been displayed in trying to identify biblical leprosy, which 
probably comprehended a number of chronic skin diseases character- 
ized by scaling or mere whiteness without scaling. Hence both 
psoriasis and vitiligo might belong here. The confusion vrith true 
leprosy doubtless arose from the fact that in the prodromal and early 
stages of leprosy, peculiar eruptions which simulated benign derma- 
toses are very common. Not less vague was the significance of 
medieval leprosy, and it is hardly worth while to attempt to trace the 
exact source of our present conception of the disease. 

WhUe there are two quite distinct varieties, of true leprosy, the 
tubercular and the anesthetic, the latter was probably known in 
earlier times only in mixed cases. The purely anesthetic type is so 
unlike tubercular leprosy that it shoxdd be separately considered. 

Lepra Tuherosa 

This type of leprosy belongs to the infectious granulomata and 
resembles other members of the group, notably syphilis and tubercu- 
losis in various ways, and especially in its ability to attack almost 
the entire integument with the upper air and food passages, involving 
destruction of the facial bones. If we bear in mind what tertiary 


j: i<«i.^ 7t 


Plate 100. 



syphilis is, it wUl at once become apparent that when the tubercles 
and nodules of leprosy appear in the skin, the disease should already 
be old, and in a late stage of development. 

The word tertiary is justifiable if we accept the theory of prom- 
inent authorities as to the primary lesion of leprosy; the secondary 
stage would imply the date of the infection of the blood. Before the 
tubercular lesions appear there are vague symptoms which point to 
the presence of a toxemia", no doubt coinciding with the blood infec- 
tion ; while paresthetic sensations of all kinds show an early implica- 
tion of the nerves at some point in their course and distribution. In 
some cases there is a transitory eruption of an erythematous type 
which is seldom recognized. At a later period macules appear, 
which are permanent and eventually become the seat of tubercles. 
These vary greatly in color, contour, etc., and often simulate ordinary 
eruptions. There is usually an increase of pigmentation, which asso- 
ciated with hyperemia gives rise to red and livid blotches on the one 
hand, or brown, black or slate-colored areas on the other. The 
individual lesions show the greatest variation in size and details in 
general. The amount and character of the'pigmentation may suggest 
a number of affections, but the leprous nature is usually -recognized 
at once by the anesthesia. 

The macules are by no means a constant phenomenon, and when 
the individual with developed leprosy appears he usually presents 
quite a different picture. The face is the part to manifest the tuber- 
ous process, as a rule, and the tubercles may appear in one of several 
localities, sooner or later symmetrically. In one patient there may 
be, for example, a few flesh-colored tubercles, closely grouped, over 
the cheek bones. The lobe of the ear is also a favorite early site, and 
merely feeling of the lobes is one of the routine ways of arriving at 
a diagnosis. Instead of these circumscribed groups, we may see a 
general infiltration of the skin of the forehead, especially of the eye- 
brows, or of the nose, lips or chin. There appears to be no law 
governing the choice of location or order of evolution. When the 
process is sufficiently diffuse and deep-seated the appearance is typi- 
cal of the disease, and is described by the term leontiasis. In some 
cases, however, the features which give to the face its expression 
are but little affected, although there may be very many tubercles 
on the forehead, cheeks and chin. The greatest disfigurement results 
from the corrugation of the forehead, the loss of the eyebrows, which 
is practically constant, the infiltration of the upper eyelids, the 
spreading of the nose and thickening of the lips. All of these may 
occur in the same subject, and in the most extreme development the 


entire face is uniformly thickened and lobulated by folds like that of 
a pachyderm — hence the designation elephantiasis. 

During the appearance of the tubercles on the face there is 
commonly a similar evolution in the nasal chambers, mouth and 
throat, and the early perforation of the septmn is sometimes regarded 
as the primary lesion of the disease, but this is unlikely. Loss of the 
nasal bones occurs, as in lupus and syphilis, in a certain proportion 
of cases. There is also a marked tendency to lepra of the larynx, 
producing aphonia, and frequently there is also destruction of the 

Despite the. severity of leprosy in the face and its accessory cavi- 
ties, the scalp enjoys almost an immunity. The deposition of the 
tubercles is usually preceded and accompanied by pigment anomalies, 
but these are of minor significance. Tubercle and nodules occur 
in aU localities outside of the face, and the nodules may reach the 
size of tumors. The diseased surface is prone to form intractable 
ulcers. The skin at large may also be uniformly thickened. Thus, in 
one leper .the hands and fingers may retain their normal contour and 
yet be the seat of many tubercles and nodules, or the entire hands 
may be swollen out of shape, the fingers resembling bananas. The 
participation of the lymphatics plays a considerable role in leprosy 
as it does in leukemic tumors and mycosis fongoides. When these 
are involved the amount of swelling and thickening is greatly 

Lepra Anestheiica 

It is of course understood that the so-called anesthetic or nerve 
leprosy may complicate ordinary tubercular leprosy, in which case 
its manifestations are overshadowed by the severity of the latter 
affection. It is also understood that in exclusively tubercular leprosy 
there is always implication of the terminal nerve filaments, so that 
anesthesia is a constant symptom. "What is meant by lepra anes- 
thetica or nervora, in the strictest sense of the term, is a limitation 
of the disease to one or more nerve trunks, or in other words isolated 
leprous neuritis. This is a not uncommon type of the disease which 
presents no further deformity than results from this one class of 
lesions. The subjects, often superior in their station, may be found 
in schools or offices or in society, with no one, not even themselves and 
their families, aware of the nature of the malady. The patient seem? 
to develop the disease in the usual manner, i.e., with obscure evidences 
of toxemia. They may also have the prodromes and early maculo- 
anesthetic lesions, but tubercles never develop. The bacillary or 
toxic cause of the disease is neurotrophic only. A neuritis develops, 


Fig. 165. Lepra ariaesthetica. 

just as it may in a number of diseases. A pemphigoid eruption often 
attends the supervention of the neuritis. 

The patients usually present themselves after the neuritis is 
fully developed. If seen early enough there may be present the 
indefinable toxic symptoms, the paresthesiaj and the preliminary 
maculo-anesthetic eruption on the trunk. The latter is not so marked 
and deep-seated as in lepra tuberosa, and does not present such wide 
diffusion or deep stains. Great variety is shown, however, in color 
and extent and presence of an atrophic element which causes lesions 
suggesting vitiligo and morphea. There is also considerable variety 
in the sensory disturbances, which may be hyperesthetic or pares- 
thetic at first, but end in anesthesia. One nerve only, usually the 
ulnar, is involved, and there may be found some macular lesions on 
the face, or perhaps not even that — only subjective anesthesia in 
limited areas. When a particular nerve trunk like the ulnar is 
involved, the picture is simply that of a severe, persistent neuritis 
with eventual trophic alterations, perhaps of the highest type. It 
is doubtful, however, if a single detail is characteristic of leprosy. 
The claw hand, the sloughing of the phalanges, the perforating ulcers 
of the sole of the foot, when the peroneal nerve is involved, are 
shown to be of leprous origin only by collateral evidence and exclu- 
sion. The neuritis of the ulnar and peroneal nerves is fully devel- 
oped, but analogous lesions on the face and trunk are much less 
typical, suggesting morphea or hemiatrophia facialis. On account of 
our ignorance of many localized trophic affections, a few authors 
look upon them as survivals of nerve leprosy. Syringomyelia, with 
its anesthesia and trophic lesions on the hands, resembles nerve 
leprosy, but is synometrical while the latter may be unilateral. There 
appears to be no reason for pure nerve leprosy being fatal. Subjects 
admittedly have lived twenty or more years. 


Leprosy is due entirely to the parasitism of Hansen's bacillus, 
which can now be cultivated and inoculated. The baciUus greatly 
resembles that of tuberculosis, and in animal experiments the two 
may be made to produce much the same lesions. All attempts to 
trace the passage of the germs into the human body have been 
unavailing. Although leprosy is prevalent in hot countries, this fact 
is a mere coincidence, for the disease also flourishes in the coldest 
countries. The abimdance of insect life in hot countries and the 
huddling together of people in vermin-infested huts in cold climates 
strongly suggests the intermediation of insects. There is no initial 
or parent lesion known in leprosy, as in some of its congeners. 


Whatever the mode of transmission, there is a notable immunity to 
the disease on the part of relatives and neighbors, and tliis may be 
an acquired immunity, for we know nothing of any minimal forms of 
the disease. The familial character suggests also an inherited 
disposition to the malady. 


Only in the earliest stages is there any difl&cnlty, and this usually 
in non-leprous countries. In the long prodromal period there are 
many vague symptoms suggesting a chronic or recurrent toxemia, 
which most naturally remind one of malaria, while the paresthesias 
may suggest various affections of the nervous system. If there is 
a pronounced macular stage antedating the tubercles, the presence of 
anesthesia is significant. There should be a special examination of 
the septum for a lesion, also of the skin of the face for the first 
tubercles. The ulnar nerve is sometimes felt to be thickened at the 
internal condyle. During the first evolution of the tubercles on the 
face, both syphilis and lupus may be simulated, but not to such an 
extent as to lead to confusion. The tuberculin test is negative in 
lepers, except in those who are also suffering from tuberculosis, but 
the Wassermann reaction is generally positive, especially in the 
nodular type of the disease. 


Leprosy tends to appear in successive exacerbations. One of 
these may not amount to a confirmed disease, for in very rare cases 
there is no succession. These self-limited cases may be responsible 
for erroneous ideas of treatment. The affection once developed is 
practically incurable. Despite the malignity of the disease, vital 
organs are not attacked, and although the patient is literally dying 
by inches and menaced by a score of other diseases by reason of 
his low vitality, he may live many years, the average being eight or 
nine or even more. The anesthesia robs the disease of much suffer- 
ing, but the patient, largely disabled by his infirmities and ostracized 
by society, is reduced to continued martyrdom. In about half the 
cases death occurs from tuberculosis. The leper somehow develops 
immunity to septic infection to which he is constantly exposed, and 
cancer is almost unknown among them. 


"VMiile segregation protects the commimity at large, emigration 
benefits the individual leper. Change of residence to a non-leprous 
country or otherwise healthy climate invariably lengthens the life 


of the patient and lessens the severity of the disease. The reverse 
is true when the patient remains in a locality where leprosy is endemic 
or when a victim of the disease is forced to associate with other 

In addition to the best dietetic and hygienic management, and the 
treatment of symptoms as they arise, the various drugs generally 
recommended as antileprous remedies should be employed. The 
best accredited of these is chaulmoogra oil. Symptomatic betterment 
nearly always follows the use of this oil, and some believe that by 
perseverance a technique may be devised by which it may become 
a veritable specific, attacking the bacillus in all the tissues. At 
present the great drawback to the use of oil is the frequency with 
which it causes gastric disturbance. As it should be given in large 
doses, its administration subcutaneously or by inunction is not very 
satisfactory. Gurjun oil and hoang-nan are drugs that have been 
extensively used in leprosy. Crocker strongly recommends the intra- 
muscular injection of bichloride of mercury. 

In the anesthetic type of the disease improvement has sometimes 
followed the administration of large doses of nuc. vomicae. Arsenic 
has often been used for its general tonic effect, and in some cases of 
tubercular leprosy apparent improvement has followed intravenous 
injections of salvarsan. The X-rays have been largely used and are 
now known to be of considerably less value than was formerly sup- 
posed. Nastin, prepared from a streptothrix found in leprous 
nodules, has recently attained considerable attention as an antileprous 
remedy. Its therapeutic value, however, has not as yet been definitely 
determined. Serums and vaccines are still in the experimental stage. 

Fig. 161. Model in Lassar's Clinic in Berlin (Kasten). 

Fig. 162. Model in Neisser's Clinic in Breslau {Kroener). 

Fig. 163. Model in St. Louis Hospital in Paris, No. 1000 (Baretta). 
Lailler's case. A leper from the Isle of Bourbon. 

Fig. 164. Model in St. Louis Hospital in Paris, No. 1217 (Baretta). Vi- 
dal's case. A leper from Calcutta. 

Figs. 165 and 166. Models from Neisser's Clinic in Breslau {Kroener). 
The daughter of a fisherman from the neighborhood of Memel, aged 
seventeen, with disturbances of sensibility; wasting, especially of the 
arms and legs, noticed for a year and a half; pigmentary and blanched 
areas on the trunk; atrophy of the hands, especially of the thenar, 
hypothenar, and interosseous muscles. 



Plate 102, Fig. 167 

This affection, which is often at the present day termed simply 
scleroma, because it is not peculiar to the nose nor does it necessarily 
begin in that organ, was originally seen only in certain localities in 
Eastern Europe, where at first it seemed to affect only Orthodox 
Jews. At a later period it was found farther west, and also among 
other races, and it is now known to occur in Central and South 
America. From its original locality in Europe it has also been 
carried into various countries, the United States included, by immi- 

Rhinoscleroma is limited to the nose, pharynx, larynx and trachea, 
the same area in fact to be attacked by ozenous affections with which 
it is thought to be in some way related. It may be primary in any 
of these localities, but in about ninety per cent, appears first in the 
nose. Its location here is the only one of dermatologic significance. 
It begins in the mucous membrane, from which locality it involves 
the cartilages and soft parts of the nose. These structures are infil- 
trated with extremely hard neoplastic tissue, and the process may 
extend to the lips, the nose becoming broad and the nostrUs narrowed. 
The actual lesion is a flattened nodule and these may remain isolated 
or be crowded together. 

The description thus far given follows that found in dermatologi- 
cal works. It is, however, a serious error to regard this affection as 
one which primarily concerns the dermatologist, who sees as a rule 
only such advanced forms as have involved the face. The rhinolarjm- 
gologist is bound to see a greater number of cases than does the 
dermatologist, for he sees the types which have not attacked the skin. 
The affection, in fact, is one of the nasal cavities which may extend 
either forward or baclrward. It seldom climbs upward, so that the 
olfactory portion of the nose is non-participating. 

The primary focus is most commonly found on the anterior region 
of the floor of the nose, or from the continuous portion of the septum 
and the contiguous area of the inferior turbinal. Even when its 


Plate 102. 








development has not transcended this locality, it is recognized by 
the rhinologist. In tlie meantime it advances in growth within the 
nasal chambers, and in many cases extends backward to involve the 
pharynx and larynx. 

The affection tends to appear in nodules, discrete or confluent, 
which cause much deformity through the resulting thickening of the 
various tissues attacked, but seldom leads to secondary changes of 
any sort. Ulceration does not often appear. 


The primary prerequisite seems to be squalor, Eace is no longer 
believed to be a prominent factor. A characteristic bacillus appears 
to be the efficient cause, one which differs in no wise from the bacillus 
ozense and bacillus of Friedlander pneumonia. Once thought to be 
a disease of adult life, it is now known to attack children. 


This could undoubtedly be made by exclusion in cases of doubt, 
but when well developed the nature of the condition should be evident. 


The disease cannot be extirpated surgically, for new nodules are 
bound to reappear. The troubles caused are entirely mechanical, and 
hence nasal and laryngeal obstruction have to be prevented, if pos- 
sible. The treatment may be summed up in radiography and auto- 
vaccino-therapy, which sometimes serve at least to clear up the 
obstructions to breathing. 

Fig. 167. Model in St. Louis Hospital in Paris, No. 1615 (Baretta). 

Besnier's case. 


Leukemia Cutis 

Plate 103, Fig. 168 

The general condition known as leukemia, from the initial blood 
state, is characterized by lymphoid tumors of certain structures along 
with a general IjTiiphoid infiltration of the viscera. Exceptionally 
both these features are seen in the skin, and the resulting condition 
of the latter bears a not inconsiderate resemblance to certain cases 
of multiple sarcoma and granuloma fungoides. The earliest manifes- 
tations in the skin, whether or not due to interference with the IjTuph 
circulation, sometimes consist of a dermatitis or eczema, which itches 
intensely, and becomes infiltrated with time. These eruptions, how- 
ever, do not pass directly into lymphomatous lesions, as might be 
expected from the analogy with granuloma fungoides. An irregular 
thickening of the skin from participation of the lymphatics also 
occurs without previous dermatitis. Both the dermatitis and the 
elephantiasis lesions occur in more or less circumscribed areas. 
Tumors occur in two principal forms. In one, the lesions are small, 
in size up to a cherry and very numerous, sometimes arranged in 
series. The other consists of individual masses which may attain 
large dimensions. All these lesions, which depend evidently on more 
or less common factors, may occur singly or in combination. The 
head and face, arms and genitoanal region are the localities of choice. 
Occurring in the face a condition of leontiasis results. The affection 
does not necessarily have a leukemic basis, for the same lesions occur 
in pseudo-leukemia or Hodgkin's disease. Despite the severity of 
the condition the lesions do not appear to undergo much retrograde 
change nor do they seem to be able to increase indefinitely. In any 
case death from the underlying disease would take place before such 
results could transpire. The prognosis for recovery is hopeless. 


In any of the affections of this tj-pe a blood count must be made 
to exclude granuloma fungoides and pseudo-leukemia. There is little 
doubt, however, that all these affections form a group disease. 


Plate 103. 

Fig. 168. Leukaemia cutis. 


The X-rays are much used at present for the general condition of 
leukemia, and from their power over neoplasms they furnish almost 
our sole resource. Arsenic injections have a certain influence in some 

Fig. 168. Model in Neisser's Clinic in Breslau- (Kroerur). 


Granulomo Fungoides 

Synonym: Mycosis fungoides 

Plate 104, Fig. 169; Plate 105, Fig. 170 

This very rare affection, first described by Alihert in 1814, pre- 
sents some notable analogies with leukemia of the skin and pseudo- 
leukemia, resembling these more than multiple sarcoma -ft-ith which 
it has sometimes been confused. In a few cases a leukemia blood 
picture has been found in tj-pieal granuloma fungoides. The most 
remarkable parallelism with leukemia lies in the initial pruriginous 
eruptions. These manifestations in the case of leukemia are said to 
point to an underlying systemic infection. In the polymorphous 
character of these exanthems, their occurrence in successive crops, 
the intense itcliing, and the chronic intractable character, we are 
reminded of some features of dermatitis herpetiformis. Eczema has 
also been exactly simulated, and even psoriasis. These eruptions 
may be more or less generalized or narrowly circumscribed. This 
preliminary phase lasts for months or years, crops of eruption suc- 
ceeding one another, until at last the presence of infiltration is noted, 
at first in small areas, causing flat nodes from pea size to that of a 
cherry. We see something of this sequence in other granulomata of 
the skin — superficial eruptions followed by nodulation. The nodules, 
however, in this case become distinct tumors, the tendency of the 
former being toward aggregation into patches. Tumors, however, 
may also arise from apparently healthy integument. Here, too, it 
may be emphasized that the so-called premycotic stage is sometimes 
lacking, the disease begimiLng entirely as multiple tumors. Notwith- 
standing their formidable characters, they sometimes undergo involu- 
tion. With the appearance of tumors there is no extinction of the 
premycotic manifestations which continue to appear. The first 
tumors are small and not numerous, but others soon appear and the 
entire surface may in time be studded with them. They tend to be 
larger in successive crops and more disposed to retrograde changes. 
They vary much in appearance and have been likened to various 


7;„ 1 An r^r-oniilnrm fiiiHTniHp'; 

objects, as tomatoes, there being a tendency to lobulation. The 
appearance presented by tumors is not to be confused with the 
changes which supervene after ulceration. The latter is not a uni- 
versal process, else the patient would hardly be able to maintain his 
general health. It is perhaps exceptional that a tumor softens and 
ulcerates at the summit, after which the proliferation from the ex- 
posed surface is of a fungoid character. In certain cases, however, 
the mushroom-like lesions may predominate, so that as in Alihert's 
first case there was a condition like yaws. The patient's general 
health, often maintained throughout, now begins to succumb to maras- 
mus, and death ensues. 


The disease is regarded by many as being of parasitic origin, 
although this as yet has not been proved. The general aspect of the 
affection is much like that of sarcoma. Blood changes are sometimes 
seen in granuloma fungoides but they show variable pictures. The 
blood changes sometimes seen — eosinophUia, polynucleosis, etc., are 
only such as may accompany toxic, infectious, and other obscure 
chronic diseases. As a matter of fact they differ in nowise from 
blood pictures seen in syphilis and tuberculosis. 

Next in interest to the blood pictures are the visceral lesions. 
The aggregate amount of study which has been bestowed on these is 
not extensive. Many of the changes are only such as would naturally 
be found in any chronic constitutional disease. The question as to 
whether do actual metastatic growths occur which are identical with 
those of the skin is naturally of the greatest importance. Lymphoid 
hyperplasia has been found at times which, however, presents nothing 
specific. It cannot be said that any of the questionable finds duplicate 
throughout in structure the tumors of the skin. There are, however, 
a few cases on record in which careful histological study of the 
viscera has revealed lesions which conform in every way to the 
cutaneous growths. Bosellini found such changes in the cortex of 
the brain which he regards as possessing analogy with luetic and 
tuberculous gummata in the same locality. 


In the early stage the affection may bear a very decided resem- 
blance to eczema, psoriasis or urticaria. In the stages of infiltration 
and tumor formation, however, the condition is unique and a diag- 
nosis may be made by exclusion. The microscopical picture is char- 
acteristic even in the early stage and a biopsy should always be made 
in suspected cases. 



The duration is very nncertain, depending largely upon the period 
at which the fungoid stage develops. After this has appeared death 
is a question of months, the utmost survival being perhaps two years. 


Constitutional treatment consists essentially in the nse of tonics 
combined with a generous diet. 

The X-rays have a very decided influence upon the sjonptoms and 
lesions of the disease. In the early stage the pruritus is greatly 
relieved and in the late stage the tumors may be made to practically 
disappear, A few years ago it was thought that with the X-rays a 
symptomatic cure could be obtained, and many of the highest authori- 
ties still look upon their employment with favor. In cases that have 
been imder my own observation, however, I am convinced that death 
followed the apparent improvement obtained by the use of the rays 
more rapidly than would otherwise have been the case. 

Arsenic is generally recommended, and has been used extensively, 
sometimes with benefit. It should be given in large doses, internally, 
and by subcutaneous injection. In one of my cases very decided 
improvement followed intravenous injections of salvarsan. Potas- 
sium iodid is occasionally of value in the fimgoid stage. 

Local treatment is merely palliative. In the prefungoid stage, 
the various antipruritic remedies used in eczema may be employed. 
In the late stage ablation of the ttmiors may be performed or the 
growths destroyed by the thermo- or electro-cautery. When the 
tumors break down antiseptic applications and dressings are indi- 
cated. Dry dusting-powders are often useful. 

Fig. 169. Model in Neisser's Clinic in Breslau (Kroener). 

Fig. 170. Model in St. Louis Hospital in Paris, No. 1706 (Baretta). 

Hallopteau's case. 

























Plate 106. 




Sarcoma Cutis 

Plate 105, Fig. 171; and Plate 106, Fig. 172 

Four varieties are described of sarcoma cutis based upon the pres- 
ence or absence of pigment and whether or not multiple. 

Single, non-pigmented sarcoma is a very rare affection and not 
highly malignant. It usually develops in a previous lesion — mole or 
wen, does not run to any particular type or types, varies extremely in 
size, shape and location, seldom attains a size larger than a fist and 
tends to be fatal through internal metastases. 

Single pigmented or melanotic sarcoma is a much more typical 
affection which may begin in a pigmented mole, but often first appears 
on the hands or feet as a bleb or felon-like lesion. Pigment is so 
essential that it may be noted before there is any tumor. The primary 
lesion not only grows with great rapidity, but metastases quickly 
appear, even in the skin and mucosae. Aside from secondary tumors 
there are simple deposits of pigment. 

Generalized or multiple non-pigmented sarcoma has no connection 
with any other form of sarcoma cutis and begins with a number of 
separate growths near together. Some of these cases appear to be 
leukemic in origin, others resemble more or less closely granuloma 
fungoides. Others again may be multiple cutaneous metastases of 
internal sarcoma. All in all, the nosologic position of this affection 
is not clear. Affections described under this name are relatively 
malignant. The lesions, unlike typical sarcoma, have considerable 
tendency to ulcerate before they attain much size. The inflammation 
which sometimes develops about these growths and the intense itching 
often present has caused them to be termed pseudogranuloma fun- 
goides. The fourth form, idiopathic multiple hemorrhagic sarcoma 
is much more readily characterized than are the preceding. It begins 
on the extremities in multiple foci, showing various shades of blackish 
or bluish. The earlier lesions may in part undergo involution, but are 
soon followed by others. The limbs may be so studded as to consti- 
tute a form of elephantiasis. An angiomatous or telangiectatic new 


formation commonly coexists, so that the tmnors bleed easily. The 
course is less malignant than in the other forms, for the patients 
often survive for many years. 


Absolutely nothing is known of the intimate nature of these affec- 
tions, beyond what is kno\\Ti of malignant disease in general. They 
occur at any age, and are much more common in males, large, vigorous 
men being often noted among the subjects. 


Aside from a few allied forms of malignancy — ^leukemic tumors 
and granuloma fungoides — there is no affection which should give 
rise to confusion, save, of course, in the very earliest stages. 

Prognosis and Treatment 

Save in the case of isolated non-pigmented sarcoma, there is no 
real remedy, not even early excision, which seems to precipitate the 
extension of a pigmented sarcoma. A few cases of cure have been 
attributed to arsenic injections. Some of the earlier nodules dis- 
appear spontaneously, so that it is credible that very exceptionally 
there may be no recurrence, and the affection is self-limited. This 
fact does not furnish any indications for successful treatment. In 
idiopathic multiple hemorrhagic sarcoma improvement sometimes 
follows the use of the X-rays. 

Fig. 171. Model in Neisser's CUnic in Breslau {Kroener). 
Fig. 172. Model in Lesser's Clinic in Berlin {Kolbow). 




Plate 107. 


Ulcus Rodens 

Plate 107, Figs. 173 and 174 

This affection is a special clinical type of epithelioma of the skin, 
which was originally confounded with lupus and termed lupus exe- 
dens. Its ultimate recognition was due chiefly to the microscope, for 
cHnicaUy it has considerable analogy with lupus, and the confusion 
is heightened by the fact that an ulcerated lupus lesion not infre- 
quently becomes an epithelioma. Some authors make a distinction 
between rodent ulcer and superficial epithelioma, but for clinical 
convenience it is best to regard the former as a mere variety of the 
latter, in which ulceration of a progressive character is the essential 
part of the disease, which may therefore cease to be superficial, 
although never becoming cancerous in the strict sense. While super- 
ficial epithelioma may develop elsewhere in rare cases, it is practically 
limited to the face and chiefly to its upper half. 

The disease, like any form of epithelioma, may begin in a pre- 
existing lesion — as a seborrheic wart, but as a rule first appears as 
a characteristic lesion — a nodule of a peculiar pearl-like lustre, but 
sometimes of a reddish, yellowish or brownish hue. These nodules 
are elevated and sharply defined, and not mere circumscribed infil- 
trations. They are softer than the surrounding tissues, from which 
they are readily scraped away with the curette. In this, as in other 
respects, a comparison with lupus vulgaris is inevitable ; but this is 
hardly worth while, because the latter almost always begins in child- 
hood, while epithelioma is a disease of advanced life. In rodent ulcer, 
loss of substance is evident from the first, and the destructive process 
may be quite rapid, so that a flat, raw surface quickly appears. A 
characteristic of rodent ulcer as compared with the ordinary form is 
the lack of any attempts at repair. There may be nothing at first 
sight about these ulcers to throw any light on their nature, although 
the fact of their occurrence about the eyelids or sides of the nose or 
temples in an elderly subject would at once suggest the disease. In 


some cases, however, a thin, pearly border is in evidence ; and it be- 
comes apparent that the tendency of the disease is for the degenerated 
tissue to ulcerate before it can become visible to the naked eye. This 
feature, coupled with the frequent inability of the centre of the lesion 
to cicatrize and the occasional tendency to attack the deeper tissues, 
suffices to differentiate rodent ulcer from the alternate form of the 
disease, Eodent ulcer has but little discharge, and this dries into a 
thin, adherent crust. 

The typical form of superficial epithelioma is a much more chronic 
affection. The pearl-like nodules may persist for months -without any 
tendency to break down, and are replaced very slowly by small losses 
of substance. A thin adhesive crust usually covers the latter, and 
reforms promptly when detached. The ulcer extends very slowly 
and new nodules at the periphery may often be seen to precede this 
extension. As the ulcer becomes larger, its entire border may be seen 
to be constituted of this new tissue. Another more or less characteris- 
tic feature is the marked tendency of the ulcer to undergo cicatriza- 
tion and retraction. It is not uncommon to see a case even untreated 
in which a large area of scar tissue makes up nearly the whole of the 
lesion, while only here and there does a small incrustation, raw sur- 
face or group of new nodules proclaim the active state of the process. 

Naturally, aU attempts to separate wholly the two forms of 
superficial epithelioma from each other or from the deep forms are 
more or less unsatisfactory because transitions sometimes occur. 
Rodent ulcers practically never cause metastases of the IjTiiph nodes, 
and on account of their chronic course in people already advanced in 
years seldom destroy life. 


One set of difficulties is connected with the initial manifestations, 
and chiefly when these occur secondarily to some preexisting lesion — 
a wart or mole. However, aU signs of activity in old lesions are uni- 
formly regarded as suspicions of a precancerous state. In senile 
warts which do not manifest themselves until advanced age it is more 
difficult to recognize precancer — in fact, impossible. The most sig- 
nificant sign is the appearance of a small crust, which announces the 
presence of an underlying abrasion or fissure, and which quickly 
reforms when detached. Other difficulties are connected with exclud- 
ing syphilitic and tuberculous ulcers, which may themselves develop 
into epithelioma. Serological tests should be of help in certain 
obscure cases. 



This depends much more on the opportunities for proper treat- 
ment than is the case with many affections because of the great 
chronicity and relative benignity of the process. Seated Ln localities 
which forbid excision as a rule, these lesions are nevertheless curable 
in the great majority of cases, even when quite far advanced. Left to 
themselves or improperly treated, there is barely any tendency to 


While these affections are not believed to originate from local 
irritation to any marked extent, it is none the less true that they some- 
times improve notably under soothing applications. These cases are 
naturally those which have been aggravated by improper treatment, 
and are much more coromon among deepseated cancers. The old name 
of "touch me not" applied to rodent idcer shows that these were 
readily aggravated by improper treatment. 

For beginning lesions and those which have not surpassed a cer- 
tain size the principal resource is the curette, followed by chemical 
cauterization. This in the majority of cases is enough to cure the 
condition as it stands, although new nodules may appear later. 

A large rodent ulcer may be excised outright in suitable localities. 
In others the raw surfaces may be destroyed by the use of the 
curette and caustics as before, but in recent years X-rays have been 
extensively used, alone and in combination with mild caustics, and 
are adapted especially to cases where severe measures would produce 
deformity and functional incapacity. 

Figs. 173 and 174. Model m Freiburg Clinic (Johnsen). Patient came 
from Jadassohn's Clinic in Berne. 


Paget's Disease of the Nipple 

Sjnonjm: Malignant papillary dermatitis 
Plate 108, Fig. 175 

This affection should be given its full title, as Paget's name is also 
associated with another, though quite dissimilar disease, osteitis 

The affection of the nipple was first described by Sir James Paget 
in 1874 in a paper based on the study of fifteen cases, and it was 
originally regarded as an eczema of the nipple and areola, to which 
carcinoma of the mammary gland is frequently consecutive. It is 
now knoT\Ti to be a malignant process practically from the beginning; 
a superficial new-growth "with a peculiar precancerous inflammatory 

The disease is not necessarily limited to the female nipple nor to 
the reproductive organs as a class, but is one that may occur in 
almost any locality. Cases have been recorded of its attacking the 
scrotum, penis, anus, axillae, umbilicus, as well as other parts. Its 
immediate interest, however, lies largely in the original disease as it 
affects the nipple. 

In seventy-five per cent, of cases the right nipple is attacked, a 
disproportion at present inexplicable. The eczema-like patch which 
first forms about the nipple is very insidious in its development and 
for a long time may present only a scaly erythema which itches more 
or less. Its circumscribed area is due in part to the fact that it is at 
first confined to the areola. It passes beyond the latter in some 
cases, but not far in its eczematous phase. The second stage presents 
a surface like eczema rubrum, raw and moist. The true nature of the 
process may generally be recognized at this stage by the sharp con- 
tour and slight sense of induration. The nipple also undergoes 
changes which could never result from mere eczema, being eroded 
and retracted. The disease now ulcerates and extends over the sur- 
face of the breast while at the same time it passes along the ducts 







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and involves the gland proper. As ulceration is taking place about 
the nipple the eczematous area may be extending at the periphery. 
It is probable that at the present day most of these cases come to 
treatment long before extreme stages are reached. 


The disease attacks the same victims as does ordinary cancer of 
the breast. Beyond this nothing is known as to causation, although 
it may be taken for granted that any kind of irritation of the nipple 
is a causal factor. 


No confusion should arise save in the earliest phase of the disease. 
At this time, when there is only a slight scaly patch with a Little 
viscid secretion, the condition might easily be confounded with ec- 
zema or dermatitis. The test of treatment should be of value here, 
as an eczema or dermatitis should readily yield to appropriate 


If seen early and treated radically the growth may generally be 
removed. The prognosis, however, in old, extensive, and neglected 
or badly treated cases is always unfavorable. 


No permanent good can result from the application of soothing 
ointments or from the employment of cauterizing agents. The growth 
is always more extensive than the cutaneous involvement would indi- 
cate and the only rational treatment is the amputation of the breast. 
The X-rays should not be employed in this affection, except possibly 
as a post-operative procedure. 

Fig. 175. Model from Pospelow's Clinic in Moscow (^Fiweishy). 


Carcinoma Linguae 

Plate 109, Fig. 176 

This lesion is, in over ninety per cent, of all cases, an epithelioma 
similar entirely to epitheliomata of the lips, floor of the mouth, etc. 
The high degree of malignancy which attends it is very seldom due to 
internal metastases and ordinary cancerous cachexia but to the power 
of rapid local extension and the high degree of glandular implication. 
The location may vary in respect to any form of irritation which dis- 
tinctly serves as a nidus for the neoplasm, but irrespective of this 
fact it usually begins at the sides or tip of the organ. 


The disease occurs in the middle-aged, and its frequency is by no 
means rare. The part played by so-called precancerous states, of 
which there are a great number, is great, but cancer in this locality 
may develop in a perfectly intact mucous membrane, and statistics 
show that at least some of these preexisting lesions are notably ab- 
sent. To enumerate the latter, there is the irritation from sharp 
teeth, leukoplakia, syphilitic lesions and scars, glossitis and Rigg's 
disease. Smoking is often accused as a source of constant irritation, 
and is undoubtedly an important etiological factor. 


Since cancerous, tuberculous and syphilitic ulcers may occur on 
the tongue, the main point is to exclude cancer, A negative Wasser- 
mann generally excludes syphilis. Tuberculous ulcers are very rare, 
the primary type especially ; the secondary form could readily be ex- 
cluded. A suspicious induration or abrasion of the tongue may often 
be recognized as cancer by excising a smaU fragment for microscop- 
ical examination. 















This varies according to the duration and extent of the growth at 
the time of operation. 


The only real benefit wrought is by early and radical operation. 

Fig. 176. Model in St. Louis Hospital in Paris, No. 1557 (Baretta). 

Hallopeau's case. 


Carcinoma Penis 

Plate 109, Fig. 177 

The first manifestation is most commonly on the glans, the prepuce 
being less frequently attacked. The initial and precancerous stages 
show considerable variation, for this is described by patients as a 
wart, pimple, raw surface, ulcer, scab, or smooth induration. The 
lesion is almost invariably an epithelioma, and however it begins, 
tends to invade the deeper tissues and proper lymph nodes. After 
it has fairly begun the progress of the disease, which may be rapid, 
follows one of two types: first a sort of rodent ulcer in which the 
lesion consists of a rapidly extending ulcer with a hard border, and 
second, a productive or papillomatous tj-pe which results in a so- 
called cauliflower cancer. The two types shade into each other. 
Although these growths may show much malignancy they are some- 
times of very slow growth lasting for a number of years ; nor do the 
glands always become involved. The proportion of cases which would 
be comparable to superficial epithelioma and rodent ulcer of the face 
is probably much larger than is commonly believed. 


Cancer of the penis has to be differentiated carefully from chan- 
cre, syphilitic gumma and tuberculous ulcer, but the classic tests 
should be sufficient for this purpose. 


This is always grave. 


A few cases may be benefited by cauterization, curettage, or 
excision, but in the great majority it is not only necessary to amputate 
the penis but to remove all of the inguinal glands as well. Recurrence 
is connnon, as elsewhere. Radium and the X-rays have their 

Fig. 177. Model in Neisser's Clinic in Breslau {Kroener). 



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